The digital rectal examination (DRE) remains important - outcomes from a contemporary cohort of men undergoing an initial 12-18 core prostate needle biopsy.

INTRODUCTION: Indications for prostate needle biopsy (PNB) include elevated serum prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE). We evaluated a contemporary cohort of men undergoing PNB to determine cancer detection rates when stratified by DRE status. MATERIALS AND METHODS: The charts of 806 men who underwent a PNB were reviewed. Serum PSA was categorized as normal or abnormal according to age-specific criteria. A normal DRE was defined as a smooth, age-appropriate, asymmetric, or uniformly enlarged prostate. An abnormal DRE was defined by either a nodule or induration. Sensitivity, specificity, and predictive values were determined for an abnormal DRE and the diagnosis of prostate cancer. RESULTS: Within the cohort, 516 patients (64%) had a normal and 290 (36%) an abnormal DRE. Three hundred six (38%) men were diagnosed with prostate cancer of which 136 (44%) had an abnormal DRE. Fourteen percent of patients with prostate cancer had an isolated DRE abnormality. Furthermore, when specifically considering these 136 men with an abnormal DRE and prostate cancer, 43 (31%) had a normal age-specific PSA value. No differences in cancer detection rate were noted when stratifying by type of DRE abnormality. In this select cohort of patients undergoing prostate biopsy, an abnormal DRE had a sensitivity of 44%, specificity of 68%, positive predictive value (PPV) of 46%, and a negative predictive value (NPV) of 67% for detecting prostate cancer on biopsy. CONCLUSION: Almost 50% of men in our cohort diagnosed with prostate cancer had an abnormal DRE. While only 14% of all patients with prostate cancer had an isolated DRE abnormality, 31% of these men had normal age-specific PSA values. Such observations underscore the importance of the DRE for prostate cancer screening.

Complications following prostate needle biopsy requiring hospital admission or emergency department visits - experience from 1000 consecutive cases.

OBJECTIVE: • To review a contemporary cohort of patients undergoing a transrectal ultrasound-guided prostate needle biopsy (TRUS PNBx) at a single centre to determine the incidence of major complications necessitating hospital admission or emergency department (ED) visits. PATIENTS AND METHODS: • The charts of 1000 consecutive patients undergoing TRUS PNBx were reviewed. • All patients received peri-procedural antibiotic prophylaxis with either ciprofloxacin or co-trimoxazole. • Hospital admission and ED visits within 30 days of the procedure were identified for indication, management and outcome. • Patient comorbidities and biopsy characteristics were reviewed for association with complications. RESULTS: • Of the 1000 patients, 25 (2.5%) had post-biopsy complications requiring hospital admission or an ED visit. • Indications included twelve patients (1.2%) with urosepsis, eight (0.8%) with acute urinary retention requiring urethral catheterization, four (0.4%) with gross haematuria requiring bladder irrigation for <24 h, and one (0.1%) with a transient ischaemia attack 1 day after biopsy. • Patients with urosepsis had an average hospitalization of 5 days, and 75% carried quinolone-resistant Escherichia coli organisms. • All patients with urinary retention had catheters removed within 10 days. No patients with haematuria required a blood transfusion. • No demographic or biopsy variables were particularly associated with development of a post-procedure complication. CONCLUSIONS: • In this large contemporary series of TRUS PNBx, we observed a 2.5% rate of major complications requiring hospital admission or an ED visit. • No clinical or biopsy variables were directly associated with development of complications. • These data may be valuable when counselling patients before biopsy.

Significant activity of single agent vinorelbine against small-cell cancer of the bladder as second line chemotherapy: a case series and review of the literature.

Small-cell carcinoma of the urinary bladder is an extremely uncommon form of urologic malignancy, accounting for less that 1% of new cases of bladder cancer. It is an aggressive malignancy which, like its pulmonary counterpart, tends to spread with distant metastases. This malignancy is generally chemotherapy and radiotherapy sensitive. Metastatic disease is typically treated with regimens active against small-cell carcinoma of the lung, such as cisplatin and etoposide. There are no data regarding second-line treatment of this cancer. We report our experience in 3 patients using the second generation vinca alkaloid, vinorelbine, in refractory metastatic small-cell carcinoma of the bladder. These 3 patients had extensive prior therapy but all 3 responded to weekly vinorelbine, with a complete response (CR) in 1, near CR in the second, and partial response in the third. Of note, the patient who sustained a CR has remained without disease and with excellent quality of life for nearly 4 years since starting vinorelbine. Indeed, the therapy was very well tolerated in all 3 patients with grade 2 cytopenia being the only toxicity. We conclude that vinorelbine is well tolerated and has activity in this case series in the second-line treatment of metastatic small-cell carcinoma of the bladder.

Preoperative predictors of surgical approach for partial nephrectomy.

INTRODUCTION: To evaluate preoperative parameters of patients undergoing partial nephrectomy to determine variables that impact selection of operative approach. MATERIALS AND METHODS: The charts of 229 consecutive patients undergoing partial nephrectomy were reviewed. Clinical data points and associated axial imaging were evaluated to determine factors which contributed to selection of an open (versus laparoscopic) operation. RESULTS: A total of 140 men and 89 women with a mean age of 57 years, body mass index (BMI) of 31, and glomerular filtration rate (GFR) of 82 mL/min/1.73 m(2) were included. Twenty-three percent of patients had prior abdominal surgery and 7% had a history of contralateral renal cell carcinoma (RCC). The mean tumor size was 3.4 cm (range, 0.7-11) with 23% of lesions being endophytic, 38% involving the collecting system, and 29% being hilar. Thirty-four patients (15%) had multifocal lesions. Overall, 130 patients underwent an open partial nephrectomy (OPN) and 99 a laparoscopic partial nephrectomy (LPN). On univariate analysis, preoperative GFR (p = 0.05), a history of contralateral RCC surgery (p = 0.02), tumor size (p = 0.04), renal sinus/collecting system involvement (p = 0.001), renal hilar location (p = 0.001), tumor multifocality (p = 0.004), surgeon laparoscopic case volume of <25 cases (p = 0.03), and lack of fellowship laparoscopic training (p = 0.02) all were associated with an open surgical approach. In a logistic regression model incorporating these eight variables, only renal hilar location (OR 2.63, 95% CI 1.17-5.88, p = 0.02) remained significantly associated with OPN. CONCLUSIONS: Many parameters including increasing BMI, preoperative GFR, prior abdominal surgery, endophytic tumor location, and renal sinus/collecting system involvement do not necessarily preclude a minimally invasive partial nephrectomy. In our experience, renal hilar tumors were over 2.5 fold more likely to be managed by OPN owing to the complexity of resection.

Use of systemic therapy and factors affecting survival for patients undergoing cytoreductive nephrectomy.

OBJECTIVE: To present a multi-institutional experience evaluating the use of systemic therapy in patients undergoing cytoreductive nephrectomy (CN), as prospective randomized trials showed a survival benefit for CN in patients with metastatic renal cell carcinoma treated with immunotherapy, and these data have been extrapolated to support CN in the era of targeted therapy, but the likelihood that patients with metastatic kidney cancer who undergo CN will receive systemic treatment afterward remains poorly defined. PATIENTS AND METHODS: In all, 141 patients who underwent CN between 1990 and 2008 were identified from our Institutional Kidney Cancer Registries. Kaplan-Meier analyses and Cox regression models were used to assess the effect of clinicopathological and perioperative variables on patients' subsequent receipt of systemic therapy, and survival after CN. RESULTS: Overall, 98 of the 141 patients (69.5%) received postoperative systemic treatment, at a median (range) of 2.5 (0.1-61.5) months after CN. In this group, 52 (53%) patients received immunotherapy, 34 (35%) targeted agents, and 12 (12%) other regimens. By contrast, 43 patients (31%) did not receive systemic therapy, because of rapid disease progression (13, 30%), decision for surveillance by medical oncology (nine, 21%), patient refusal (10, 23%), perioperative death (eight, 19%), and unknown reasons in three (7%). The median (range) survival after CN was 16.7 (0-120) months. The risk of death after surgery correlated with the number of metastatic sites (P = 0.012) and symptoms (P = 0.001) at presentation, poor performance status (P = 0.001), high tumour grade (P = 0.006), and presence of sarcomatoid features (P < 0.024). CONCLUSION: Nearly a third of patients undergoing CN did not receive systemic treatment. While some were electively observed or declined therapy, others did not receive treatment due to rapidly progressive disease. Further investigation is warranted to identify those patients at highest risk of rapid postoperative disease progression who might benefit instead from an initial approach to treatment with systemic therapy.

Durability of the Malone antegrade continence enema in pregnancy.

The Malone antegrade continence enema (MACE) is a therapeutic option to treat chronic constipation and fecal incontinence in patients with neurogenic bowel. Previous reports have described the short-term success of this procedure, but no report has described the durability of the procedure during pregnancy. We present the case of a spinal cord injury patient who underwent an uncomplicated pregnancy after a MACE procedure with no stomal catheterization difficulties or leakage during or after the pregnancy.