Successful surgical resection and reconstruction of scrotal elephantiasis.

INTRODUCTION: An enlarged scrotum due to scrotal elephantiasis results in a poor quality of life. This condition is uncommon and challenging to manage for most urologists. We report a case of scrotal elephantiasis treated with resection and scrotal reconstruction. CASE PRESENTATION: A 57-year-old man was referred to our hospital with a 6-year history of scrotal swelling. The scrotum was 20 cm in diameter, stiff, and thick. He was diagnosed with chronic scrotal lymphedema and underwent scrotal resection. The skin and subcutaneous tissues of the scrotum were excised, and the suprapubic skin, which was stretched by the enlarged scrotum, was used for the scrotal reconstruction. The penis was pulled out from this hole in the skin. CONCLUSION: Utilizing suprapubic skin flap for scrotal reconstruction is an effective treatment for scrotal elephantiasis that can result in functionally and cosmetically successful outcomes.

[A Case of Primary Mediastinal Seminoma Showing Local Increase in Residual Tumor after Chemotherapy].

A 19-year-old man with abnormal findings on his chest X ray was referred to our hospital. A chest computed tomography scan revealed a 57 mm mass in the anterior mediastinum, and percutaneous needle biopsy was performed. Histopathological diagnosis was pure seminoma. Since the serum alphafetoprotein (AFP) level was normal and no abnormal findings were noted in the testis, the patient was diagnosed with mediastinal seminoma [International Germ Cell Consensus Classification (IGCCC) goodrisk group]. After three cycles of chemotherapy with bleomycin/etoposide/cisplatin [BEP], the tumor decreased in size to 32 mm, and a fluorodeoxyglucose-positron emission tomography scan indicated negative tumor findings. After four months, the residual tumor increased in size to 40 mm without any increase in the tumor marker levels. Surgical resection was performed, and the histopathological finding was only mature teratoma. Six months after the operation, there has been no recurrence.

The third national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from complicated urinary tract infection patients.

The antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using national surveillance data. The data consisted of 881 bacterial strains from eight clinically relevant species. The data were collected for the third national surveillance project from January 2015 to March 2016 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was undertaken with the cooperation of 41 medical institutions throughout Japan. Fluoroquinolone required a MIC90 of 2-64 mg/L to inhibit the 325 Escherichia coli strains tested and the proportion of levofloxacin resistant E. coli strains increased to 38.5% from 29.6% in 2011 and 28.6% in 2008. The proportion of levofloxacin resistant strains of Pseudomonas aeruginosa and Enterococcus faecalis decreased from previous reports and the proportion of multidrug-resistant P. aeruginosa and carbapenem-resistant Enterobacteriaceae remained low. Among methicillin-resistant Staphylococcus aureus (MRSA) strains, strains with reduced susceptibility to vancomycin (minimum inhibitory concentration, 2 µg/mL) increased to 14.7% from 5.5%. Bacterial strains that produced extended-spectrum ß-lactamase included E. coli (79 of 325 strains, 24.3%), Klebsiella pneumoniae (9 of 177 strains, 7.7%), and Proteus mirabilis (6 of 55 strains, 10.9%). The proportion of extended-spectrum ß-lactamase producing E. coli and K. pneumoniae strains increased from previous surveillance reports.

[A Case of Ureteral Sciatic Hernia Treated with Ureteral Stent].

An 83-year-old woman who was diagnosed with hydronephrosis on the right side was referred to our hospital. An abdominal computed tomography scan failed to reveal the cause of the hydronephrosis due to artifacts caused by her artificial hip joint. A subsequent magnetic resonance imaging scan revealed a ureteral herniation into the sciatic foramen. Retrograde pyelography demonstrated hydronephrosis and dilated ureter loopsthrough the sciatic foramen, known asa "curlicue sign". A ureteral stent was placed on her right side, and the ureter waslinearized. After the stent wasplaced, the hernia wasrepaired and the hydronephrosiswasres olved. The ureteral stent wasremoved 3 monthslater, and relapse of the ureteral sciatic hernia did not occur, even after 18 months.

Radiation recall pneumonitis induced by nivolumab in a patient with renal cell carcinoma.

INTRODUCTION: A radiation recall reaction in previously irradiated lungs is known as radiation recall pneumonitis. We encountered a rare case of radiation recall pneumonitis induced by nivolumab 9 months after palliative radiotherapy to the ribs. CASE PRESENTATION: The patient was a 69-year-old woman with renal cell carcinoma. She had received various drugs and palliative irradiation, which was followed by nivolumab treatment, for renal cell carcinoma. Three days after the initial nivolumab administration, she presented with respiratory symptoms. On the basis of chest computed tomography findings, she was diagnosed with nivolumab-induced radiation recall pneumonitis and treated with prednisolone (1 mg/kg). The condition resolved rapidly, and chest computed tomography 4 months after nivolumab cessation revealed interval resolution of the lung consolidation and persistent tumor shrinkage. CONCLUSION: Physicians should consider the risk of radiation recall pneumonitis during treatment with immune checkpoint inhibitors in patients who have received previous thoracic radiotherapy.

[Right Essential Renal Hematuria that Can Not Be Coagulated with a Ureteroscope Treated by Hydrogen Peroxide Instillation : A Case Report].

We report a case of right essential renal hematuria treated by hydrogen peroxide instillation. A twentythree-year-old man visited our hospital with gross hematuria, urinary retention and right pelvic pain. Our diagnosis was right renal essential hematuria. A bleeding point was found in the right renal calix using a flexible ureteroscope. Bleeding was prolonged in spite of ureteroscopy and diathermy fulguration. We performed treatment with hydrogen peroxide instillation. The patient made a satisfactory recovery postoperatively, and no complications have been observed. Retrograde hydrogen peroxide instillation therapy is a useful treatment for essential renal hematuria that can not be coagulated with a ureteroscope.

[A Case of Secondary Extramammary Paget's Disease Aroundthe Cutaneous Stoma after Radical Cystectomy].

We present a case of secondary extramammary Paget's disease around the cutaneous ureterostomy stoma after radical cystectomy. An 85-year-old man with bacillus calmette-guérin refractory high-grade urothelial carcinoma underwent radical cystectomy and cutaneous ureterostomy construction. After right ureter cancer diagnosis, he underwent right nephroureterectomy 3 years after the cystectomy. He developed refractory dermatitis around the cutaneous stoma 1 year after the nephroureterectomy. Skin biopsy revealed secondary extramammary Paget's disease, cured by skin excision around the cutaneous stoma and skin grafting. Multiple urothelial carcinoma metastases were detected 6 months later ; he died of urothelial cancer 1 month later.

[Clinical Outcomes of Anteroposterior Dissection Holmium Laser Enucleation of the Prostate for Benign Prostatic Hyperplasia].

Holmium laser enucleation of the prostate (HoLEP) is a standard surgical procedure for treatment of benign prostatic hyperplasia (BPH). A low incidence of postoperative urinary incontinence in association with anteroposterior dissection HoLEP was recently reported. We evaluated 66 patients with BPH who underwent anteroposterior dissection HoLEP from March 2013 to November 2014. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, maximum flow rate (Qmax), and post-void residual urine volume (PVR) were assessed preoperatively and at 1 and 3 months after treatment. The incidence of postoperative urinary incontinence, which was defined as the requirement of more than one pad per day, was compared between the first and second half of the patient population. Postoperative urination parameters (IPSS, QOL index, Qmax, and PVR) were significantly improved. The incidence of urinary incontinence at 3 months was significantly lower in the second half (4%) than first half (28%) of the patient population (p＝0.020). In conclusion, anteroposterior dissection HoLEP is an effective procedure for the treatment of BPH and can reduce the rate of postoperative urinary incontinence, even in low-volume institutes.

Japanese nationwide surveillance in 2011 of antibacterial susceptibility patterns of clinical isolates from complicated urinary tract infection cases.

To investigate antimicrobial susceptibility patterns of various bacterial pathogens isolated from complicated urinary tract infection (UTI) cases, the Japanese Society of Chemotherapy, the Japanese Association of Infectious Disease, and the Japanese Society of Clinical Microbiology conducted the second nationwide surveillance from January to September 2011. With the cooperation of 42 medical institutions throughout Japan, 1036 strains belonging to 8 clinically relevant bacterial species were collected. Among methicillin-resistant Staphylococcus aureus (MRSA) strain, the vancomycin (VCM) MIC for 5.5% (3/55) of the strains was 2 µg/mL. Ampicillin, VCM, and linezolid were relatively active against 209 Enterococcus faecalis strains. The proportion of fluoroquinolone (FQ)-resistant strains was >20%. The MIC90 of FQs against the 382 Escherichia coli strains was 2-64 mg/L and the proportion resistant to FQs was approximately 30%. However, susceptibility of E. coli to sitafloxacin was still high (MIC90 = 2 mg/L). Fifty-eight (15.2%) of 382 E. coli, 6 (4.5%) of 132 Klebsiella pneumoniae, 1 (2.4%) of 41 Klebsiella oxytoca and 4 (6.8%) of 59 Proteus mirabilis strains were suspected of producing extended-spectrum beta-lactamase. Of 93 Pseudomonas aeruginosa strains, the proportions resistant to imipenem, amikacin, and ciprofloxacin were 21.5%, 4.3%, and 20.4%, respectively. Four strains (4.3%) were found to be multidrug-resistant. In complicated UTI cases, all of MRSA and E. faecalis were susceptible to all anti-MRSA agents. Sitafloxacin was active against other FQ-resistant E. coli strains. The isolation of extended-spectrum beta-lactamase-producing and multidrug-resistant strains increased.

[Scrotal desmoid tumor in a patient with familial adenomatous polyposis].

A 46-year-old man presented to our hospital for further examination following a positive fecal occult blood test. He also had a painless, palpable scrotal mass that had been present for several years, but he had not previously sought treatment. Colonoscopy demonstrated multiple adenomatous polyps and colon cancer ; when taken together with his family history, these findings led to the diagnosis of familial adenomatous polyposis. A computed tomography scan revealed a right intrascrotal tumor, and the patient was referred to our department. Together with digestive surgeons, we carried out scrotal mass resection and colectomy under general anesthesia. On scrotal exploration, a large, solid mass was identified ; it was separate from the testis and epididymis. Although the mass was adhered to the surface of the corpus cavernosum penis, we were able to completely resect the mass along with part of the corpus cavernosum penis. The tumor was composed of abundant collagen fibers and mature fibroblasts. Histopathology revealed the right scrotal mass to be a desmoid tumor. The patient is alive with no evidence of disease 24 months after surgery.

[Clinical outcomes after non-ischemic partial nephrectomy for clinical T1 renal tumors using soft coagulation versus microwave tissue coagulation].

PURPOSE: We have performed non-ischemic partial nephrectomy for clinical T1 renal tumors using microwave tissue coagulation (MTC group) or soft coagulation (soft coagulation group). The clinical outcomes were retrospectively compared between the two groups. MATERIALS AND METHODS: A total of 36 patients were analyzed in this study (22 in the MTC group and 14 in the soft coagulation group). The anatomical characteristics of the renal tumors were assessed using the R.E.N.A.L Nephrometry Score. Renal function was assessed by the estimated glomerular filtration rate. RESULTS: The preoperative estimated glomerular filtration rate was 72.1 ml/min in the MTC group and 65.6 ml/min in the soft coagulation group (p = 0.05). The R.E.N.A.L Nephrometry Score was not significantly different between the two groups. Clavian grade > or = 2 postoperative complications occurred in one patient (4.5%) in the MTC group and one patient (7.1%) in the soft coagulation group. Postoperative local recurrence and distant metastasis occurred in one patient (8.3%) in the soft coagulation group and no patients in the MTC group, which was not a significant difference between the two groups. The median postoperative decrease in estimated glomerular filtration rate was 11.5% in the MTC group and 3.6% in the soft coagulation group. Postoperative renal preservation tended to be better in the soft coagulation group than in the MTC group, but this difference was not significant. CONCLUSION: The use of soft coagulation in non-ischemic partial nephrectomy for the treatment of clinical T1 renal tumors is as effective as that of MTC.

[Primitive neuroectodermal tumor of kidney : a case report].

A 16-year-old man was referred to our hospital for asymptomatic gross hematuria. The findings of abdominal ultrasonography were normal. A month later, gross hematuria disappeared, and he was not followed after that. A month later, the patient was taken to our hospital in an ambulance for severe back pain and recurring gross hematuria. Computed tomography (CT) revealed a large right renal tumor with tumor thrombus penetrating inside the inferior vena cava. The patient underwent radical nephrectomy and embolectomy. The pathological diagnosis of the tumor was diagnosed as primitive neuroectodermal tumor (PNET) of kidney by immunostaining and gene analysis. We started adjuvant chemotherapy soon after the operation. However, at 10 months after, multiple pulmonary metastases were detected. The patient was treated with salvage chemotherapy, surgery and irradiation therapy as combined modality therapy. Nevertheless, he died 18 months after the diagnosis.

Oral bisphosphonate prevents bone loss in androgen deprivation therapy for nonmetastatic prostate cancer.

We studied the short-term efficacy of alendronate, an oral bisphosphonates, on bone mineral density (BMD) during androgen deprivation therapy (ADT) in 45 nonmetastatic prostate cancer patients at the beginning of ADT (treatment group). All received alendronate five mg daily from the initiation of ADT. Lumber BMD was evaluated by dual energy X-ray absorptiometry, at baseline and after six months of treatment. Historical data on 24 patients with prostate cancer who received ADT without bisphosphonate administration were studied as controls (control group). BMD decreased in 13.9 and 45.8% of the patients in the treatment and control groups, respectively. Mean BMD changes in the lumber spine were +1.6 +/- 3.0% in the treatment group and -1.1 +/- 2.7% in the control group (p = 0.006). No pathological fractures occurred during the study period. No severe adverse effects were observed, but three patients could not continue alendronate treatment because of adverse events. Despite the short-term of this evaluation, our results showed that oral alendronate is an effective and safe treatment for preventing bone loss and increasing BMD in patients receiving ADT for prostate cancer.

Individual variation of hormonal recovery after cessation of luteinizing hormone-releasing hormone agonist therapy in men receiving long-term medical castration therapy for prostate cancer.

OBJECTIVE: To evaluate the process of hormonal recovery after cessation of luteinizing hormone-releasing hormone (LHRH) agonist treatment in patients who had received long-term LHRH agonist therapy for prostate cancer. MATERIAL AND METHODS: Men who had successfully undergone androgen deprivation therapy with only monthly LHRH agonist therapy for > 30 months were enrolled and the administration of LHRH agonist was discontinued. Serum total testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prostate-specific antigen (PSA) were measured before the cessation of LHRH agonist therapy and every 4 weeks thereafter, and the administration of LHRH agonist remained suspended until the total testosterone level recovered to > 50 ng/dl. RESULTS: Ten patients were enrolled in the study. The median (range) castration period and the levels of serum LH, FSH, total testosterone and PSA at cessation of therapy were 39 (30-56) months,<0.5 (<0.5-1.8) mIU/ml, 6.4 (3.0-15.9) mIU/ml, 15.3 (5.8-34.7) ng/dl and 0.13 (0.02-0.89) ng/ml, respectively. Testosterone recovered to > 50 ng/dl in all cases. There were large variations in the times required for recovery of LH and FSH (30-100 days) and serum testosterone (30-330 days). PSA began to increase at various testosterone levels, and there was a large variation (0-83%; median 41%) in the ratio of the androgen suppression (testosterone < 50 ng/dl) time to the period of LHRH agonist cessation. CONCLUSIONS: There was considerable variation in the hypothalamus-pituitary-testicular hormone profiles during recovery from long-term medical castration. These findings are noteworthy when interruption of androgen deprivation therapy is applied with the intention of delaying the progression of hormone-refractory cancer or improving the patient's quality of life.

Impact of IGF-I and CYP19 gene polymorphisms on the survival of patients with metastatic prostate cancer.

PURPOSE: The prognosis of metastatic prostate cancer significantly differs among individuals. While various clinical and biochemical prognostic factors for survival have been suggested, the progression and response to treatment of those patients may also be defined by host genetic factors. In this study, we evaluated genetic polymorphisms as prognostic predictors of metastatic prostate cancer. PATIENTS AND METHODS: One hundred eleven prostate cancer patients with bone metastasis at the diagnosis were enrolled in this study. Thirteen genetic polymorphisms were genotyped using polymerase chain reaction-restriction fragment length polymorphism or an automated sequencer with a genotyping software. RESULTS: Among the polymorphisms, the long allele (over 18 [CA] repeats) of insulin-like growth factor-I (IGF-I) and the long allele (over seven [TTTA] repeats) of cytochrome P450 (CYP) 19 were significantly associated with a worse cancer-specific survival (P = .016 and .025 by logrank test, respectively). The presence of the long allele of either the IGF-I or CYP19 polymorphisms was an independent risk factor for death (P = .019 or .026, respectively). Furthermore, the presence of the long allele of both the IGF-I and CYP19 polymorphisms was a stronger predictor for survival (P = .001). CONCLUSION: The prognosis of metastatic prostate cancer patients is suggested to be influenced by intrinsic genetic factors. The IGF-I (CA) repeat and CYP19 (TTTA) repeat polymorphisms may be novel predictors in prostate cancer patients with bone metastasis at the diagnosis.

Prostate cancer detection among men with prostate specific antigen levels of 2.5 to 4.0 ng/ml in a Japanese urological referral population.

PURPOSE: Prostate cancer detection at levels of 2.5 to 4.0 ng/ml in a Japanese urological referral population has not been elucidated. The purpose of this study is to investigate the cancer detection rate and clinical relevance of prostate cancer in this PSA range. MATERIALS AND METHODS: All urological patients 70 years or younger tested for prostate cancer were studied. There were 550, 97, 112 and 52 patients with a PSA of less than 2.5, 2.5 to 4.0, 4.1 to 10.0 and more than 10.0 ng/ml, respectively. Transrectal 10-core prostate biopsy was performed in 80 (82%) of the 97 patients with a PSA of 2.5 to 4.0 ng/ml and 102 (91%) of the 112 patients with a PSA of 4.1 to 10.0 ng/ml. RESULTS: Cancer detection rates in patients who underwent biopsy were 26.3% and 34.3% at PSA levels 2.5 to 4.0 and 4.1 to 10.0 ng/ml, respectively. High grade cancers with Gleason score 7 or more were found in 19.0% and 22.9% of patients with cancer with PSA 2.5 to 4.0 and 4.1 to 10.0 ng/ml, respectively. No significant difference was found between the 2 groups in pathological findings on biopsy, including percent positive cores (16.7% vs 20.0%, p = 0.10), maximum cancer length (25.0% vs 30.0%, p = 0.28) and maximum percent cancer length (2.0 vs 3.0 mm, p = 0.17). CONCLUSIONS: Japanese urological referral patients develop prostate cancer quite commonly even if their serum PSA levels are 2.5 to 4.0 ng/ml. Since these cancer cases include high grade, clinically significant cancer, prostate biopsy might be considered at least for selected cases in this PSA range.

Value of prostate volume measurement using transabdominal ultrasonography for the improvement of prostate-speci fi c antigen-based cancer detection.

PURPOSE: To examine value of prostate-speci fi c antigen (PSA) adjusted by prostate volume measured using transabdominal ultrasonography in prostate cancer detection among men with elevated PSA. METHODS: 238 men aged 79 years or younger with serum PSA levels of 2.0-20.0 ng/mL and normal digital rectal examination fi ndings were studied in terms of total and free PSA, prostate volumes with transrectal (TRUS) and transabdominal (TAUS) ultrasonography and transition zone volumes with TRUS prior to transrectal 10-core biopsy. In addition to sole PSA values and the free-to-total PSA ratio, volume-adjusted PSA values, PSA densities determined by TRUS (PSAD(TRUS)), and TAUS (PSAD(TAUS)), and PSA transition zone densities (PSATzD) were compared using receiver operating characteristic (ROC) analysis. RESULTS: Prostate cancer was diagnosed in 58 (24.4%) of the 238 men who underwent prostate biopsies. Of the areas under ROC curves (AUC) of studied parameters, PSATzD (AUC 0.751) was the best and signi fi cantly superior to PSAD(TAUS) (AUC 0.664, P = 0.007). However, PSAD(TAUS) exceeded PSA (AUC 0.559, P = 0.004) and showed potential capability of a one-fourth reduction in unnecessary biopsies without spoiling sensitivity (90%). Cancer detection rate was only 4.2% in the 48 patients whose prostate volume in TAUS was > 50 mL and PSAD(TAUS) was < 0.075. CONCLUSIONS: Since PSAD(TRUS) and PSATzD were signi fi cantly superior to PSAD(TAUS), TRUS is feasible as the standard fashion to determine prostate volume in the diagnosis of prostate cancers. However, TAUS is also worthwhile as it can improve the prostate cancer detection using sole PSA, and primary use of TAUS has the potential to reduce the substantial number of unnecessary biopsy safely.

Prostate gland volume is a strong predictor of biopsy results in men 70 years or older with prostate-specific antigen levels of 2.0-10.0 ng/mL.

PURPOSE: The incidence of prostate cancer, benign prostatic enlargement and serum level of prostate-specific antigen (PSA) increase with patient age. Intermediate elevation of PSA in elderly populations is apt to be considered insignificant. We evaluated the impact of PSA and prostate volume on the presence of non-palpable prostate cancer in elderly men with an intermediate level of PSA. MATERIALS AND METHODS: Clinical records of 154 men 70 years or older, with non-cancerous digital rectal examination findings and with serum PSA levels of 2.0-10.0 ng/mL, who underwent initial 6- to 10-core transrectal prostate biopsy, were reviewed for prostate volume, number of biopsy cores, PSA and associated parameters. Stepwise logistic regression and receiver operating characteristic (ROC) models were used to determine the impacts of the parameters on the biopsy results. RESULTS: Overall cancer detection rate was 40/154 or 26.0%. Prostate-specific antigen showed no significant association with the presence of prostate cancer (P = 0.59, Mann-Whitney U-test), while prostate volume did (P < 0.0001). On stepwise logistic regression analysis, prostate volume (P = 0.024, 95% CI 1.008-1.116) and biopsy core density (P = 0.017, 95% CI 4.76-7.12 x 10(6)) were independently associated with a cancer diagnosis, whereas PSA density was not an independent factor for a positive biopsy result. The area under the ROC curve for prostate volume was significantly superior to that of PSA (0.802 vs. 0.529; P = 0.012). CONCLUSIONS: In men 70 years or older with gray zone PSA, prostate cancer patients are equally distributed over any PSA range. Although PSA has less impact on cancer presence than mere prostate volume, prostate cancer would be detected in a substantial proportion of older patients with PSA levels of 2.0-10.0 ng/mL.

Use of effective core volume obtained from transrectal biopsies for predicting target tumor volume.

OBJECTIVES: To evaluate, in a retrospective review, whether the concept of effective core volume is useful for predicting the volume of a tumor focus identified by transrectal needle biopsy of the prostate gland. METHODS: The tumor volume range was estimated according to the concept of an effective core volume using the numbers of total and positive biopsy cores from the peripheral zone and peripheral zone prostate volume in 32 patients with prostate cancer with one to three cancer-positive cores who only underwent radical prostatectomy after transrectal prostate biopsy. The estimated tumor volume was compared with the actual tumor volume as determined by pathologic examination of whole mount sections of the prostatectomy specimens. RESULTS: In the 32 patients, the actual tumor volume was within the range determined by the effective core volume concept in 24 patients (75.0%), although 4 (12.5%) had a smaller focus and 4 (12.5%) a larger focus than estimated. Overall accuracy improved up to 84.4% (27 of 32) if 5% safety margins were applied to the range determined by the effective core volume concept. In particular, the accuracy was 87.5% (14 of 16) in patients with one positive core after transrectal systemic biopsy. CONCLUSIONS: The effective core volume can be used to predict the volume of prostate cancer with acceptable accuracy. It can provide an assumed maximal tumor volume and valuable information for clinical decision making of the treatment strategy, particularly in cases with one positive core.

Age-associated increase of prostate-specific antigen in a high level of men visiting urological clinics.

OBJECTIVES: To evaluate the distribution of serum prostate-specific antigen (PSA) levels as a function of age in men with no evidence of prostate cancer who visited urological clinics. METHODS: Simultaneous measurements of total PSA and PSA-alpha-1-antichymotrypsin (PSA-ACT) were performed on patients who presented at urological clinics in Japan. After excluding 490 patients because of follow-up biopsy findings indicating prostate cancer, patients' history of prostatic surgery and medication affecting the serum PSA level, 1520 patients with PSA levels of less than 20.0 ng/mL were available for the study. RESULTS: Medians (95th percentile) of the total PSA levels were 0.9 (4.7), 1.2 (5.6), 1.7 (11.0), 2.1 (9.8) and 2.8 (11.0) ng/mL in men in their 40s (n = 37), 50s (n = 211), 60s (n = 488), 70s (n = 609) and 80s (n = 175), respectively, whereas those of PSA-ACT were 0.5 (2.9), 0.7 (3.7), 1.1 (7.4), 1.2 (5.9) and 1.6 (6.4) ng/mL, respectively. Both total PSA and PSA-ACT increase with aging, although comparison between the 10-year age groups showed a significant difference in the two molecular forms only between men in their 50s and 60s. CONCLUSIONS: The PSA ranges of men who visited urological clinics were higher than those of men participating in prostate cancer screening programs reported in other published studies. An age-associated increase in PSA similar to screening populations was also observed in urological outpatients. The results of the present study indicate that age-adjusted PSA cut-off levels can be used in outpatient settings, although the PSA reference value derived from the screening population should be carefully applied to symptomatic men of clinical practices.