Patients with Persistently Elevated PSA and Negative Results of TRUS-Biopsy: Does 6-Month Treatment with Dutasteride can Indicate Candidates for Re-Biopsy. What is the Best of Saturation Schemes: Transrectal or Transperineal Approach?

To identify patients who actually need a re - biopsy, based on alterations in PSA readings after 6-month treatment with Dutasteride. We also sought to bring out the most beneficial re-biopsy scheme. We have reviewed the records of patients with persistently elevated PSA and at least one set of TRUS biopsies. Patients who were treated with alpha -blockers/Dutasteride combination were considered as the study group, while patients in control received alpha-blockers alone. Patients in both groups underwent re-biopsy 6 months later. The two protocols of re-biopsies were used at that time: 20-24 cores saturation transrectal (ST)) and ≥ 40 cores saturation transperineal template-guided (STT) biopsies. One hundred thirty-three patients were included in this study. In 86.7 % of the patients in the study group mean PSA decreased from 7.4 ± 2.69 to 4.037 ± 1.53 (p-0.001). The overall cancer detection rate was 29 % (n-39: 19 v/s 20, control and study groups, respectively). In the study group PSA decreased to 26.73 ± 11.26 % in patients with cancer, compared with 40.54 ± 13.3 % in patients without. It must be emphasized that STT-biopsies detected significantly more cancers (38.46 v/s 20.59 %, p- 0.005). Mean cores number got to 21 ± 2.45 and 45 ± 5.65 in ST and STT biopsies, respectively. Six-month treatment with Dutasteride decreases PSA readings in 86.7 % of the patients. A PSA decline of less than 40% (cutoff) should be considered as an indicator for re-biopsy. Transperineal template-guided biopsies had a higher cancer detection rate.

7 to 10 years' follow-up of 573 patients with elevated prostate-specific antigen (>4 ng/mL) or/and suspected rectal examination: biopsies protocol and follow-up guides.

PURPOSE: In this study, we tried to design a scheme for performing transrectal ultrasonographic (TRUS)-biopsies that would be accurate and include the optimal number of cores. PATIENTS AND METHODS: We included in this study 600 consecutive patients with suspicious findings on a per-rectum examination and/or an elevated prostate-specific antigen (PSA) (>4 ng/mL) level. Patients were followed for 7 to 10 years. In all patients, we took from 8 to 16 biopsy samples, according to the prostate volume, from the lateral aspects. In the second session, the biopsy samples were taken medially; in the third session, we included the transitional zone, while in consecutive sessions, we increased the number of cores from all areas. RESULTS: Only 573 of the patients remained in follow-up. TRUS-biopsy detected prostate cancer (PCa) in 257 patients (44.85% overall detection rate). The detection rate in the first and second sessions was 32.98% and 14.94%, respectively, reaching 13.2% and 2.17%, in the third and fourth sessions, respectively. Prostate volumes were significantly smaller (52.9 +/- 22.4 cc vs 58.9 +/- 23.8 cc, P < 0.002) and the PSA/adenoma/prostate volumes ratio (ad-pro) ratio was higher (18.3 +/- 9 vs 13.96, P < 0/001) in the patients with PCa. Patients with PCa underwent fewer biopsy procedures and biopsy sessions than patients without a diagnosis of PCa (14.9 +/- 8.9 vs 20.4 +/- 12, P < 0.001;1.3 +/- 0.6 vs 1.7 +/- 0.9, P < 0.001). Biopsy samples obtained from the base were positive for cancer only in larger prostates with a mean volume of 54.3 +/- 15.3 cc. Numbers of biopsy procedures and PSA/ad-pro ratio were the strongest predictive factors for PCa detection (P < 0.001). CONCLUSIONS: In patients with a prostate volume >or=53 cc and PSA/ad-pro ratio >or=18, the optimal biopsy cores should be >or=15. Using this scheme, the discontinuation of biopsy procedures might be considered after three consecutive sessions.

Patients with elevated serum PSA and indwelling catheter after acute urinary retention: prospective study of 63 patients with 7-year follow-up.

BACKGROUND AND PURPOSE: Elevated PSA value in the presence of an indwelling catheter is still an enigma. The aims of this prospective study were: to investigate the reliability of elevated PSA levels in patients with normal DRE and indwelling catheter after AUR; to assess the impact of preoperative TRUS-biopsy in detecting prostate cancer in such circumstances; to estimate the crucial duration of follow-up period. PATIENTS AND METHODS: 63 patients were included in the study. PSA was assessed 5 days after catheter insertion. All patients failed to void without catheter and have been scheduled for surgery. TRUS-biopsy was performed before operation. All patients underwent surgery at least two weeks after prostate biopsies. Postoperative follow-up visits continued for at least 7 years. Biopsies were taken when indicated by persistently elevated PSA or an abnormal DRE. RESULTS: Mean PSA before catheter insertion differed significantly from PSA obtained on the 5(th) day after AUR (p = 0.001). Mean prostate volume calculated on TRUS was 80.5 +/- 28 ml. Mean duration of indwelling catheter placement was 37.8 +/- 7.97 days. Mean delay in operative treatment as a result of preoperative evaluation was 23.548 +/- 2.487 days. Carcinoma was detected in 13 patients, while clinically insignificant cancer was present in 31% (4 patients). It must be also emphasized that 38% of patients with carcinoma were >70 year-old. Preoperative TRUS-biopsy and postoperative pathologic exam diagnosed carcinoma in 5 patients (2 and 3 respectively). During 42 months of 7-year follow-up cancer was revealed in 8 patients. Mean PSA value in the follow-up period was significantly elevated in patients with carcinoma: 5.99 +/- 3.34 v/s 2.34 +/- 1.68 ng/ml (p = 0.007) and was the strongest predictor for cancer detection (p = 0.001). CONCLUSIONS: The detection rate of clinically significant cancer on preoperative biopsies postoperative pathologic exam in patients with AUR and indwelling catheter is low. These patients could be safely operated on without any delay. However, in order to detect clinically important cancer in the peripheral zone a postoperative monitoring period of should be recommended: starting 6 months after operation and continuing subsequently for at least 4 years. Postoperative PSA level is the strongest predictor of cancer detection and could be usefully employed in these patients. AUR and in the patients with large prostate cause elevated PSA. Cancer detection rate on preoperative biopsies is low in these patients. Long postoperative monitoring period should be strongly recommended.