Transrectal ultrasound-guided prostate rebiopsy: How many core sampling should be applied to which patient?

BACKGROUND: We investigated the correlation between the sampled number of cores in rebiopsy and the cancer detection rate (CDR). MATERIALS AND METHODS: Two hundred and twelve patients with normal rectal examination who had undergone rebiopsy in the past 5 years were examined retrospectively. Moreover, 68% of them had undergone 12 cores (Group 1) while 32% had undergone 20 cores (Group 2). Both groups were compared with respect to the CDR. RESULTS: There was no difference between groups in terms of age, total prostate-specific antigen, and prostate volume (P > 0.05). Forty-one (19%) of 212 patients were diagnosed with cancer, and the CDR was significantly higher in Group 2 (30.9% vs. 13.9%, P = 0.004). This rate increased from 6.5% to 20% (P = 0.025) and from 0% to 33.3% (P = 0.023), respectively, with 12-core and 20-core rebiopsies in patients whose initial pathology indicated benign and high-grade prostatic intraepithelial neoplasia (HGPIN). Furthermore, cancer was detected in 24 (40%) of 60 patients who were diagnosed with atypical small acinar proliferation (ASAP) in the initial biopsy. However, despite being higher in 20-core biopsy group (47.6% vs. 35.9%), this was not statistically significant (P = 0.377). CONCLUSIONS: At least 20 cores should be sampled in rebiopsy, especially in the patients diagnosed with benign and HGPIN. However, we believe that standard systematic sampling will be sufficient for the patients diagnosed with ASAP.

Assessment of PSA-Age volume score in predicting positive prostate biopsy findings in Turkey.

OBJECTIVES: To evaluate PSA-age volume (AV) scores in predicting positive prostate biopsy findings in Turkey. MATERIALS AND METHODS: PSA-AV was calculated by multiplying the patient's age by the prostate volume and dividing it by the PSA level. Sensitivities and specificities of the PSA-AV were assessed by retrospective analysis of findings from 4,717 prostate biopsies. RESULTS: The population's average age was 63.71±7.63 years, the mean PSA level was 9.73±17.01ng/mL, the mean prostate volume was 44.46±23.88 cm3. Of the 4,717 prostate biopsies, 1,171 biopsy specimens (24.8%) were positive for prostate cancer. A PSA-AV score of 700 had a sensitivity and specificity of 95% and 15%, respectively. These values were similar to the sensitivity and specificity for a PSA cut-off of 4ng/mL (94% and 13%, respectively). Although the sensitivity of a PSA-AV cut-off of 700 in patients over 60 years was similar to the PSA cut-off of 4ng/mL and the age-adjusted PSA, in patients < 60 years, its sensitivity was higher. While the sensitivities of a PSA-AV cut-off of 700 in patients with low prostate volume was higher than a PSA cut-off of 4ng/mL, the sensitivities of both methods with moderate prostate volumes were similar. CONCLUSIONS: Considering all the biopsies, the sensitivity and specificity of a PSA-AV of 700 for predicting positive biopsy findings were similar to a PSA of 4ng/mL. We suggest the PSA-AV cut-off of 700 should only be used in patients younger than 60 with low prostate volumes (< 20cm3).

How many cores should be taken in a repeat biopsy on patients in whom atypical small acinar proliferation has been identified in an initial transrectal prostate biopsy?

OBJECTIVE: To compare cancer detection rates according to the number of biopsy cores in patients on whom a repeat prostate biopsy was performed for atypical small acinar proliferation (ASAP). MATERIALS AND METHODS: The data of 4950 consecutive patients on whom prostate biopsies were performed were assessed retrospectively. A total of 107 patients were identified as having ASAP following an initial prostate biopsy, and they were included in the study. A six-core prostate biopsy (PBx) was performed on 15 of the 107 patients, 12 PBx on 32 patients, and 20 PBx on 60 patients. Cancer detection rates were compared according to the number of biopsy cores. The localization of the cancer foci was also evaluated. RESULTS: The cancer detection rates in patients on whom 6 PBx, 12 PBx, and 20 PBx were performed were 20% (3/15), 31% (10/32), and 58% (35/60), respectively, and a statistically significant difference was found (p = 0.005). When cancer detection rates in patients with total prostate specific antigen (PSA) < 10ng/mL, PSA density ≥ 0.15, normal digital rectal examination, and prostate volume ≥ 55mL were compared according to the number of biopsy cores, a significant difference was identified (p = 0.02, 0.03, 0.006, and 0.04, respectively). Seventy-five percent of the foci where cancer was detected were at the same and/or adjacent sites as the ASAP foci in the initial biopsy, and 54% were identified in contralateral biopsies in which ASAP foci were present. CONCLUSION: As the biopsy core number increases, the cancer detection rate increases significantly in patients on whom a repeat biopsy is performed due to ASAP. The highest cancer rate is found in 20-core repeat biopsies performed equally from all foci.

How many cores should be taken in a repeat biopsy on patients in whom atypical small acinar proliferation has been identified in an initial transrectal prostate biopsy?

Objective To compare cancer detection rates according to the number of biopsy cores in patients on whom a repeat prostate biopsy was performed for atypical small acinar proliferation (ASAP). Materials and Methods The data of 4950 consecutive patients on whom prostate biopsies were performed were assessed retrospectively. A total of 107 patients were identified as having ASAP following an initial prostate biopsy, and they were included in the study. A six-core prostate biopsy (PBx) was performed on 15 of the 107 patients, 12 PBx on 32 patients, and 20 PBx on 60 patients. Cancer detection rates were compared according to the number of biopsy cores. The localization of the cancer foci was also evaluated. Results The cancer detection rates in patients on whom 6 PBx, 12 PBx, and 20 PBx were performed were 20% (3/15), 31% (10/32), and 58% (35/60), respectively, and a statistically significant difference was found (p = 0.005). When cancer detection rates in patients with total prostate specific antigen (PSA) < 10ng/mL, PSA density ≥ 0.15, normal digital rectal examination, and prostate volume ≥ 55mL were compared according to the number of biopsy cores, a significant difference was identified (p = 0.02, 0.03, 0.006, and 0.04, respectively). Seventy-five percent of the foci where cancer was detected were at the same and/or adjacent sites as the ASAP foci in the initial biopsy, and 54% were identified in contralateral biopsies in which ASAP foci were present. Conclusion As the biopsy core number increases, the cancer detection rate increases significantly in patients on whom a repeat biopsy is performed due to ASAP. The highest cancer rate is found in 20-core repeat biopsies performed equally from all foci. .

Novel technique of cytolithotripsy for large bladder stones.

INTRODUCTION: We evaluated a minimally invasive surgical technique involving a single percutaneous access with a laparoscopic trocar under video-cystoscopic vision for managing large bladder stones. All patients were candidates for open surgery. MATERIALS AND SURGICAL TECHNIQUE: Fourteen patients with bladder stones larger than 3 cm in diameter or multiple stones were treated with this technique. The procedure involved the percutaneous placement of a laparoscopic trocar under cystoscopic control and the introduction of a rigid nephroscope into the bladder. Stones were cleansed via fragmentation or direct removal. DISCUSSION: The technique was successful in all cases, resulting in controlled, stone-free bladders; there were no surgical complications. The mean operation time was comparable to that of standard management. All patients discharged uneventfully. None reported urethral stricture during the 24-month follow-up period. Percutaneous cystolithotripsy under endoscopic control is easy to perform and should be considered as an alternative for large or multiple bladder stones as it decreases the risk of urethral stricture.

The effect of antibiotherapy on prostate-specific antigen levels and prostate biopsy results in patients with levels 2.5 to 10 ng/mL.

PURPOSE: This controlled prospective study aims to investigate the possible effects of antibiotic treatment on prostate-specific antigen (PSA) and its derivatives, and consequently on the transrectal biopsy rates, in the diagnosis of prostate cancer. PATIENTS AND METHODS: One hundred and forty patients aged 45 to 70 years old, with a PSA level between 2.5 and 10 ng/mL and normal digital rectal examinations (DRE), were included in this study between June 2009 and November 2010. The patients were randomly assigned into two groups. The first group received oral levofloxacin 500 mg 1*1 for 21 days; the second, the control group, was given no treatment. Initially, total PSA, free PSA, a DRE, urinary ultrasonography (including prostate volume, postvoiding residual urine), uroflowmetry, International Prostate Symptom Score, National Institutes of Health Chronic Prostatitis Symptom Index, and International Index of Erectile Function tests were performed. All of these were repeated at the end of 3 weeks of antibiotic treatment. An additional PSA measurement was also performed at day 10 of the treatment. All patients underwent transrectal ultrasonography (TRUS) guided prostate biopsy at day 21, just the day after the final (third) PSA sampling. RESULTS: The mean age of the patients was 59.6 years. Overall, in 23 patients, prostate cancer was detected, including those found in the rebiopsies. Statistically, there were significant changes in values of PSA and its derivatives in the treatment group (from 5.31 to 4.69 and 4.58 ng/mL, consecutively). Focusing on prostate cancer patients in both the treatment and control groups, however, we did not detect any significant change in the same parameters. CONCLUSION: Antibiotic treatment given to the patients with a PSA level between 2.5 and 10 ng/mL can be beneficial, before a decision for TRUS guided prostate biopsy, just in a limited subgroup, by reducing the PSA levels below the threshold value. Considering the large population of patients in the gray zone, however, it still does not provide clear solid evidence for avoiding unnecessary prostate biopsies.

Development of a quality of life scale specific for patients with benign prostatic hyperplasia.

PURPOSE: The improvement of quality of life (QoL) should be the major concern in any proposed treatment modality for any disorder. The objective of this study was to develop a new easy to use benign prostatic hyperplasia (BPH)-specific QoL scale that may guide the treatment policy in BPH. METHODS: A total of 118 items addressing BPH-specific QoL were produced. After an elimination process, a 20-question scale was developed. This new scale, Short Form (SF)-36 and International Prostate Symptom Score (IPSS), was then administered to 50 healthy men (control group), and 108 BPH patients who received medical or surgical treatment. Reliability assessment consisted of internal consistency evaluation by the Cronbach's alpha reliability test. In construct validity, factor analysis was performed using principal component analysis with Varimax rotation. Response to change of this new form was also evaluated. RESULTS: Cronbach's alpha coefficient of this scale was found to be 0.8464. Item-total correlation coefficients were between 0.3298 and 0.7886 (p < 0.0001). Factor analysis for construct validity revealed four factors. The correlation coefficients were found to be r = 0.801 (p < 0.0001) with the total IPSS, and this new QoL scale had a relatively sufficient correlation with all domains of the SF-36. Moreover, a QoL score obtained by the summation of individual grades of each item may provide valuable information just like total IPSS. The mean QoL score was 4.96 ± 9.58 and 20.28 ± 9.14 in controls and BPH patients, respectively (p < 0.0001). Moreover, QoL score significantly improved by both medical and surgical treatment. CONCLUSIONS: The new BPH-specific QoL was shown to be reliable and valid.

Prognostic factors in radical cystectomy affecting survival.

INTRODUCTION: The aim of the study was to evaluate the prognostic factors in radical cystectomy affecting survival. MATERIAL AND METHODS: A total of 100 hundred patients were included in the study. Incontinent diversion was applied to 73 of these, and continent diversion to 27. Prospective and retrospective data of the patients were examined. The prognostic value for survival was evaluated for of lymph node involvement, tumor grade (low grade: grade 0-II, high grade: ≥ III or epidermoid carcinoma), tumor stage (low stage: stage pT0-2, high stage: stage ≥ 3a pT3a), presence of preoperative unilateral of bilateral hydronephrosis, presence of preoperative uremia (serum urea value: ≤ 60), and age (> 70 and ≤ 70 years of age) on survival were investigated. Kaplan-Meier survival analysis and Log-Rank statistical methods were used in the study. RESULTS: Grade, stage, uremia, and lymph node involvement had significant effects on survival (p values 0.0002, 0.03, 0.01, and 0.02, respectively). Presence of preoperative hydronephrosis and age had no statistically significant effects on survival (p values 0.8 and 0.2, respectively). CONCLUSIONS: Tumor grade, tumor stage, preoperative uremia, and lymph node involvement are prognostic factors affecting survival. Advanced age and presence of preoperative hydronephrosis have no prognostic value for survival. The presence of uremia in the preoperative assessment of the patients is more important than hydronephrosis.

Expression of NOS isoforms in internal spermatic veins of infertile men with varicocele.

Although varicocele is a relatively common entity encountered in the evaluation of infertile men, the exact pathophysiology still remains unclear. Recently, as previously widely investigated in various parts of human circulatory system, nitric oxide synthase (NOS) and its product, nitric oxide (NO) have been thought to play a role in the development of varicocele and thus male infertility. In this study, we determined the concentration of NO metabolite and the expression of NOS isoforms in the internal spermatic (ISV) and superficial branch of inferior epigastric veins of infertile men with varicocele. The study included 60 infertile men with clinically unilateral or bilateral varicocele. Expression of inducible and endothelial NOS (iNOS and eNOS) isoforms were investigated in tissue arrays of internal spermatic and superficial branch of inferior epigastric veins with immunohistochemistry. NO metabolite (nitrite) levels were measured using the calorimetric method. A significantly higher expression of eNOS was observed in the varicose veins (mean score: 2.25 and 1.55, respectively; p = 0.0001). However, statistically, there was no significant difference for expression of iNOS between varicose and control veins (p = 0.094). The nitrite concentration and NOS expression were not found to be correlated with clinical variables (varicocele grade, maximum varicose vein diameter, and sperm concentration, motility, and morphology) (p > 0.05). As a result, the significantly higher expression of eNOS in ISV may be responsible for the development of varicocele, although this finding is not accompanied by an increase in NO concentration. Still, the pattern of the relationship between varicocele and increased eNOS expression warrants further investigation.

Is prophylactic breast radiotherapy necessary in all patients with prostate cancer and gynecomastia and/or breast pain?

PURPOSE: We investigated the efficacy of prophylactic radiotherapy for gynecomastia/breast pain induced by 150 mg bicalutamide in a prospective, randomized, multi-institutional trial. MATERIALS AND METHODS: After definitive treatment for localized prostate cancer 125 patients were randomized to 12 Gy radiotherapy before bicalutamide as prophylactic radiotherapy (53) or bicalutamide only for nonprophylactic radiotherapy (72). The incidence of gynecomastia, breast pain and tenderness, and discomfort perceived by the patients was assessed by physical examination and direct questioning at 3, 6 and 12 months of followup. RESULTS: At the end of 12 months the gynecomastia rate was 15.8% in the prophylactic group and 50.8% in the nonprophylactic group (p <0.001). On patient evaluation the breast enlargement rate was 34.4%. The severity of breast pain and tenderness was not different between the groups. The breast pain rate was 36.4% and 49.2% by 12 months in the prophylactic and nonprophylactic groups, and the rate of patients who felt discomfort from gynecomastia was 11.4% and 29.5%, respectively. CONCLUSIONS: In this prospective study the incidence of gynecomastia was not as high as previously believed. Although prophylactic breast irradiation seemed to decrease the gynecomastia rate in patients on 150 mg bicalutamide, our study proves that not all patients need prophylaxis since only 52% were significantly bothered by gynecomastia. Thus, individual assessment is needed to select patients who need prophylactic radiation while on 150 mg bicalutamide.

Validation of 2001 Partin tables in Turkey: a multicenter study.

OBJECTIVE: Although Partin tables were developed in United States to predict the stage of prostate cancer preoperatively, they are used by many clinics throughout the world assuming that these figures apply to their population as well. However the predictive value of current Partin tables, which was updated in 2001, has not been validated in most of the countries as well as in Turkey. Therefore, we evaluated the validity of 2001 Partin tables, for the ability to predict the pathological stage in Turkish patients. PATIENTS AND METHODS: The clinical and pathological findings of 1043 patients who have had radical prostatectomy were assessed. Serum PSA values, clinical stage, biopsy Gleason score and the pathological features of the radical prostatectomy specimens were collected from each clinic and evaluated. The predictive value of Partin nomogram and pathological findings of prostatectomy specimens were compared and analyzed according to Receiver Operating Characteristics (ROC) analysis. RESULTS: Median age of the patients was 60 (45-74). In the presented study, percentage of patients with clinical stage T1c was 43%. Patients with Gleason score of 2-4 in biopsy constituted 23.4% of the study group. In the present study, the ratio of the patients with serum PSA higher than 10 ng/ml was 39.6%. Organ confined disease, seminal vesicle involvement, lymph node metastases ratios were 64.7%, 10.3%, 1.8% respectively. Area Under Curve (AUC) values for organ confined disease, seminal vesicle involvement and lymph node involvement were calculated as 0.665, 0.733 and 0.759 respectively. CONCLUSION: It appears that Partin tables have a reasonable predictive value for the final pathological features like organ confined disease, seminal vesicle and lymph node involvement in Turkish patients. This multicenter study showed that current Partin tables could also be used in Turkish patients with comparable accuracy.

When should quality of life be measured after radical cystectomy?

AIM: In this prospective study our aim was to establish the time it takes cystectomized patients' to adapt to their new health status. MATERIALS AND METHOD: A total of 68 patients, having radical cystectomy for bladder cancer (64 males and 4 females) were enrolled in the study. The mean age of the group was 55.4 +/- 8.0 years (range 38-70 years). Continent urinary diversion was applied to 17 while the rest had incontinent urinary diversions. There was no statistical difference between those who had continent and incontinent diversions in regard to pre-operative stage. All patients were given a Beck's Depression Inventory (BDI), an EORTC-QLQ C-30 Version 2 (European Organization for Research on Treatment of Cancer Quality of Life Questionnaire C-30 Version 2) quality of life measurement scale pre-operatively, and post-operatively 3, 6, 12 and >12 months (every 6 months). Log-rank and Student's t-test was used for statistical analysis of the results. RESULTS: The mean follow-up of the study group was 27.7 +/- 7.3 months (range 12-46 months). Five patients at the first 3rd-month control, seven at the 6th-month control and eight at the 12th-month control did not appear for interview, but their available results were also included in the overall assessment. The mean functional score of the study group, evaluated by QLQ C-30, was 80 +/- 25.4 pre-operatively. There is dramatic decrease at the 3rd-month control (56.9 +/- 25.1; p < 0.01). The overall functional score after 12 months (80 +/- 20) is back to the pre-operative value. The mean symptom score of the group pre-operatively was 29.5 +/- 16.7, which showed similar results at 3 and 6 months post-operatively of 29.8 +/- 16.7 and 30.6 +/- 19.4, respectively (p > 0.05). At the 12th-month and thereafter the symptom scores of the patients decreased significantly in comparison to both the pre-operative and the post-operative 3-6 months (23.4 +/- 13.7 and 21.8 +/- 18.5, respectively; p < 0.01 for all). The self-rating general health status of this group was lowest pre-operatively with a mean of 49.8 +/- 26.5. Interestingly, there was a statistically significant increase in the general health status assessment of the patients even at the early post-operative period of 3 months (61.4 +/- 17.2; p < 0.01). The increase in the well-being of the patients increased linearly until the 12th-month control and stabilized thereafter. There was a 23% pre-operative depression rate, which comes down to 16% at the 12th-month control. The peak depression scores suggesting depression are observed at the 3rd-month controls. There is a gradual decrease in depression score starting from the 6th-month controls and all reach minimum scores after 12 months. Ninety-six percent of the study group showed scores even lower than the pre-operative ones. The mean pre-operative and post-operative 12th-month control scores were 11.5 +/- 7.7, and 8.1 +/- 6.8, respectively (p < 0.01). CONCLUSION: Both psychological and health-related quality of life measures come to baseline values and stabilize after the 12th-month period, suggesting that the time frame for the adaptation of patients is 12 months in patients undergoing radical cystectomy surgery. Therefore, we believe it is better to perform any quality of life assessment as an end-point criterion for comparison of treatment modalities in radical cystectomy patients after 12 months.