Primary epithelioid hemangioendothelioma of the penis: a case report and literature review.

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumour with an intermediate behaviour between benign hemangioma and malignant angiosarcoma. There is scarce data on the penile EHE's management and its natural history, as our knowledge is based on few reported cases with a short follow-up period. We present a case report and conducted a literature review, including 17 cases. The relevance of this case report derives from the need for better clinical characterization of patients with penile EHE and the importance of defining the outcomes. We report the case of a 53-year-old male with a 1-year history of sleep-related painful erections. Imaging techniques showed a well-defined hypoechoic and hypervascular solid nodule on the dorsal aspect of the penis. It was surgically removed, and the histopathological study revealed a low-risk EHE of the penis. Follow-up magnetic resonance imaging (MRI) and computed tomography did not demonstrate local recurrence nor metastases. According to the literature review, most of the patients were in their fifth and sixth decades of life at the time of diagnosis and lesions were usually located in the glans. The most common clinical presentation was as a painful mass. Follow-up period ranged from 2 months to 5 years. Three patients showed systemic metastases, two of which died due to cancer. The conclusions from the literature review are limited by the reduced number of cases and the short follow-up. This case report highlights the importance of understanding the diagnosis and treatment of this type of rare non-squamous malignant tumours of the penis. Penile EHE is a malignant vascular tumour that is very rare in this location. The best treatment is local excision, with re-excision or intraoperative margins assessment. Occasionally, systemic chemotherapy and radiation therapy can be useful. There is consensus on the importance of very strict follow-up of these patients.

Identifying Risk Factors for MRI-Invisible Prostate Cancer in Patients Undergoing Transperineal Saturation Biopsy.

PURPOSE: Prostatic multi-parametric magnetic resonance imaging (mpMRI) has markedly improved the assessment of men with suspected prostate cancer (PCa). Nevertheless, as mpMRI exhibits a high negative predictive value, a negative MRI may represent a diagnostic dilemma. The aim of this study was to evaluate the incidence of positive transperineal saturation biopsy in men who have negative mpMRI and to analyse the factors associated with positive biopsy in this scenario. PATIENTS AND METHODS: A retrospective study of men with normal mpMRI and suspicion of PCa who underwent saturation biopsy (≥20 cores) was carried out. A total of 580 patients underwent transperineal MRI/transrectal ultrasound fusion targeted biopsies or saturation prostate biopsies from January 2017 to September 2020. Of them, 73 had a pre-biopsy negative mpMRI (with Prostate Imaging - Reporting and Data System, PI-RADS, ≤2) and were included in this study. Demographics, clinical characteristics, data regarding biopsy results and potential predictive factors of positive saturation biopsy were collected. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for MRI-invisible PCa. RESULTS: The detection rate of PCa with saturation biopsy in patients with negative MRI was 34/73 (46.58%). Out of 34 MRI-invisible prostate cancers detected, 12 (35.29%) were clinically significant PCa (csPCa) forms. Regarding factors of positive biopsy, in univariate analysis, the use of 5-alpha reductase inhibitors and free:total prostate-specific antigen (PSA) ratio were associated with the result of the saturation biopsy. In multivariate analysis, only an unfavourable free:total PSA ratio remained a risk factor (OR 11.03, CI95% 1.93-63.15, p=0.01). Furthermore, multivariate logistic analysis demonstrated that prostate volume >50mL significantly predicts the absence of csPCa on saturation biopsy (OR 0.11, 95% CI 0.01-0.94, p=0.04). CONCLUSION: A free:total PSA ratio <20% is a risk factor for MRI-invisible PCa. Saturation biopsy could be considered in patients with suspected PCa, despite having a negative MRI.

Bibliographic review about the usefulness of ultrasound contrast media in the study of renal masses.

OBJECTIVES: The microbubbles enhanced ultrasound contrast is a novel technique that informs us in real time of renal perfusion and microcirculation. METHOD: We reviewed the literature about its use in the study of renal masses in order to show their actual clinical performance in this condition. RESULT: This technique is useful in the differential diagnosis of pseudotumors, characterization and monitoring of small renal masses, the study of complex renal cysts and controlling the progression of renal masses that underwent ablative treatments. Like any diagnostic technique has some limitations on usage;its rapid contrast wash, being operator-dependent, require some experience and need special software to be correctly interpreted. CONCLUSIONS: The microbubbles enhanced ultrasound contrast is a useful and economic technique for the study and differential diagnosis of the renal masses.

Revisión bibliográfica sobre la utilidad de los contrastes ecográficos en el estudio de las masas renales / Bibliographic review about the usefulness of ultrasound contrast media in the study of renal masses

OBJETIVO: La ecografía realzada con contraste de microburbujas es una técnica novedosa que nos informa en tiempo real de la perfusión renal y su microcirculación. MÉTODOS: Hemos revisado la literatura sobre su uso en el estudio de las masas renales con el fin de mostrar su rentabilidad clínica real en esta patología. RESULTADOS: Esta técnica resulta útil en el diagnóstico diferencial de pseudotumores, en la caracterización y seguimiento de masas renales de pequeño tamaño, en el estudio de quistes renales complejos y en el control evolutivo de masas renales sometidas a tratamientos ablativos. CONCLUSIONES: Como toda técnica diagnóstica, no está exenta de limitaciones de uso, siendo sus principales inconvenientes la rapidez del lavado del contraste, el ser operador-dependiente, requerir de cierta experiencia y la necesidad de un software especial para su correcta interpretación(AU)

OBJECTIVES: The microbubbles enhanced ultrasound contrast is a novel technique that informs us in real time of renal perfusion and microcirculation. METHOD: We reviewed the literature about its use in the study of renal masses in order to show their actual clinical performance in this condition. RESULT: This technique is useful in the differential diagnosis of pseudotumors, characterization and monitoring of small renal masses, the study of complex renal cysts and controlling the progression of renal masses that underwent ablative treatments. Like any diagnostic technique has some limitations on usage; its rapid contrast wash, being operator-dependent, require some experience and need special software to be correctly interpreted. CONCLUSSIONS: The microbubbles enhanced ultrasound contrast is a useful and economic technique for the study and differential diagnosis of the renal masses(AU)

[Ultrasonography for the study of small renal masses]. / Estudio ultrasonográfico de las masas renales de pequeño tamaño.

OBJECTIVES: To perform an update on the usefulness of ultrasound in the study of small size renal tumors and its current possibilities. METHODS: We review the results of ultrasound in this pathology with the addition of the most recent technological advances such as a harmonic digital converters and power color Doppler. We analyze its contribution to the differential diagnosis of the cystic pathology, to the definition of solid masses, to the detection and characterization of small size masses, and to the definition of the vascular patterns of various tumors. RESULTS: Ultrasonography offers a diagnostic safety of 98% in cystic masses, being able to detect them from 0.5 cm diameter in favourable conditions. The differential diagnosis of multiloculated masses, multivesicular hydatid cyst, multiloculated cystic nephroma, and multiloculated cystic carcinoma still poses great difficulty, the same way it happens with other radiological tests. For solid masses, the greater image resolution has lead to a progressive increase in the incidental detection of tumors and the percentage of patients candidates to conservative surgery due to the decrease in size. It is easy to differentiate between adenocarcinoma and angiomyolipoma, up to 85% of the cases, but the rest of the tumors do not have specific characteristics. For small size masses, smaller than 3 cm, ultrasound sensitivity is clearly inferior to CT scan. Power color Doppler helps to confirm the existence of solid masses and helps a better differential diagnosis with pseudo tumors. CONCLUSIONS: The modern ultrasound techniques provide a high cost-effectiveness both in detection and definition of the nature of small size renal masses.

[Transrectal ultrasound-guided prostatic biopsy: contribution of an ultrasound diagnostic unit after ten years of experience]. / Biopsia transrectal ecodirigida de próstata: aportación de una unidad urológica de diagnóstico ecográfico tras 10 años de experiencia.

OBJECTIVES: Although transrectal ultrasound-guided (TRUS) prostatic biopsy is the procedure of choice for the diagnosis of prostate cancer (PC), neither the ideal number of cores nor the number of repeated biopsies, nor the required diagnostic yield have been established. After our experience of ten years with TRUS biopsy we perform a review of the technique and its indications. METHODS: PSA, ultrasound features, and pathologic data of 6000 patients undergoing modified sextant TRUS biopsy between 1994 to December 2002 were collected. 222 patients undergoing ten-core TRUS biopsy were included in an experimental group to study the role of the extended biopsy. The contribution of the extra cores to the diagnostic yield in the experimental group was studied to determine the effectiveness of the extended biopsy, using as a control group 552 patients undergoing sextant TRUS biopsy during 2002. Both groups were comparable for the study variables at the start of the study. RESULTS: The incidence of PC in the first biopsy in the group of 6000 patients was 39.1% (2345/6000). Patients with PSA between 4 and 10 ng/ml have an incidence of PC greater than 50% among prostates smaller than 20 cc, diminishing down to 8.9% in those greater than 50 cc. The percentage of PC among patients with negative digital rectal examination (DRE), normal TRUS, and PSA below 4 ng/ml was 16.7%. The diagnostic yield for PSA density lower than 0.11 ng/ml/cc was lower than 8%. The free/total PSA ratio shows a 13.7% incidence of PC with values higher than 0.24. Multivariate logistic regression analysis showed that the only non-significant parameter was free/total PSA. Sixty (27.15%) patients of the extended TRUS biopsy group had PC. Only 2.25% of the 221 patients benefited from the augmented number of biopsies. There were no significant differences in the figures of prostate cancer between groups. Only PSA and volume where significant in the multivariate logistic regression analysis; number of samples, PSA density and age lacked of influence in the detection of PC. CONCLUSIONS: The sextant biopsy model obtaining cores from the lateral horns of the prostate continues to be the reference for TRUS biopsy, and the extended biopsy is not applicable to all patients from the beginning do to the small increase in the diagnostic yield. Isolated PSA may not be the unique reference to indicate TRUS biopsy, being volume, in our experience, a definitive factor for the adjustment of high risk levels.

[The role of transrectal ultrasound on prostatic cryotherapy and brachytherapy]. / Papel de la ecografía transrectal en crioterapia y braquiterapia prostáticas.

OBJECTIVES: Transrectal ultrasound is the method that gives a direct image of the prostate, its limits, structural and morphologic anomalies, and anatomical relations. Therefore, prostate volume is easily determined, being the first step for the application of certain therapeutic procedures. Prostatic cryotherapy and brachytherapy have been developed over the last years as minimally invasive options for the treatment of prostate cancer. Transrectal ultrasound of the prostate has allowed the application of these technologies in the daily practice, guaranteeing high efficacy and safety indexes. Cryosurgery is the controlled freezing of tissues. Prostatic transrectal ultrasound is the only method able to show the real-time evolution of prostatic cryoablation, allowing the urologist to control the evolution of the ice ball and to reach the targeted anatomical structures guaranteeing the oncological objectives, and diminishing complications and sequels. Brachytherapy, as a local intraprostatic radiotherapy, needs exact volume and dose calculations before the implant of the radioactive source within the gland. With transrectal ultrasound of the prostate, ultrasound-tomographic cuts are made for prostatic volume calculation and planimetry Once dosimetry is completed, real-time transrectal ultrasound control is necessary to perform the implant of the needles loaded with the seeds. Today, prostate cryotherapy and brachytherapy would be inconceivable without transrectal ultrasound.

[Testicular ultrasonography]. / Ecografía testicular.

OBJECTIVES: To review the contribution of ultrasound to the differential diagnosis of scrotal pathology, both testicular and adnexal. METHODS: We performed a bibliographic review on the topic, adding the experience of our Unit over the years; we classified the pathology in testicular and extratesticular, separating liquid and solid lesions, and a miscellaneous group of unclassifiable cases. RESULTS: Currently, ultrasonography with high frequency equipment allows not only to differentiate between intra and extratesticular lesions, but also to identify specific lesions, the manage of which may include follow-up without need of unavoidable surgery. CONCLUSIONS: Ultrasonography is a painless simple test that may be repeated without inconvenience so that it is the first test to be indicated for any problem of the scrotal content.

Estudio ultrasonográfico de las masas renales de pequeño tamaño / Ultrasonography for the study of small renal masses

OBJETIVO: Efectuar una puesta al día de la utilidad de la ecografía en el estudio de los tumores renales de pequeño tamaño y de las posibilidades que esta técnica ofrece en el momento actual. MÉTODO: Revisión de los resultados obtenidos en esta patología con las aportaciones ofrecidas por los desarrollos tecnológicos más recientes como los convertidores digitales con modo armónico y el Doppler color energía. Análisis de su contribución al diagnóstico diferencial con la patología quística, a la definición de las masas sólidas, a la detección y caracterización de las masas de pequeño tamaño y a la definición de los patrones vasculares de los diferentes tumores. RESULTADOS: La ecografía ofrece una seguridad diagnóstica del 98% en las masas quísticas pudiéndose objetivar en condiciones favorables a partir de un diámetro de 0,5 cm. El diagnóstico diferencial de las masas multitabicadas, quiste hidatídico multivesicular, nefroma quístico multilocular y carcinoma quístico multilocular, sigue planteando graves dificultades, al igual que ocurre con el resto de las técnicas de imagen. En las masas sólidas la mayor resolución de las imágenes ha conducido a un incremento progresivo en la detección de tumores incidentales y en el porcentaje de pacientes candidatos a cirugía conservadora dada la continua disminución en su tamaño. La diferenciación entre el adenocarcinoma y el angiomiolipoma es fácil y posible en el 85% de los casos no presentando el resto de tumores características específicas. En las masas de pequeño tamaño, menores de 3 cm., la sensibilidad de esta técnica es claramente inferior a la de la TAC. El Doppler color energía ayuda a confirmar la existencia de las masas sólidas y permite un mejor diagnóstico diferencial con los seudotumores. CONCLUSIONES: Las modernas técnicas ecográficas ofrecen una elevada rentabilidad tanto en la detección como en la definición de la naturaleza de las masas renales de pequeño tamaño

OBJECTIVES: To perform an update on the usefulness of ultrasound in the study of small size renal tumors and its current possibilities. METHODS: We review the results of ultrasound in this pathology with the addition of the most recent technological advances such as a harmonic digital converters and power color Doppler. We analyze its contribution to the differential diagnosis of the cystic pathology, to the definition of solid masses, to the detection and characterization of small size masses, and to the definition of the vascular patterns of various tumors. RESULTS: Ultrasonography offers a diagnostic safety of 98% in cystic masses, being able to detect them from 0.5 cm diameter in favourable conditions. The differential diagnosis of multiloculated masses, multivesicular hydatid cyst, multiloculated cystic nephroma, and multiloculated cystic carcinoma still poses great difficulty, the same way it happens with other radiological tests. For solid masses, the greater image resolution has lead to a progressive increase in the incidental detection of tumors and the percentage of patients candidates to conservative surgery due to the decrease in size. It is easy to differentiate between adenocarcinoma and angiomyolipoma, up to 85% of the cases, but the rest of the tumors do not have specific characteristics. For small size masses, smaller than 3 cm, ultrasound sensitivity is clearly inferior to CT scan. Power color Doppler helps to confirm the existence of solid masses and helps a better differential diagnosis with pseudo tumors. CONCLUSIONS: The modern ultrasound techniques provide a high cost-effectiveness both in detection and definition of the nature of small size renal masses

Biopsia transrectal ecodirigida de próstata: aportación de una unidad urológica de diagnóstico exográfico tras 10 años de experiencia / Transrectal ultrasound-guided prostatic biopsy: contribution of an ultrasound diagnostic unit after ten years of experience

OBJETIVO: A pesar de que la Biopsia Transrectal Ecodirigida (BTE) prostática es el método fundamental de diagnóstico del cáncer prostático (CP) no se ha establecido el número ideal de muestras, de repeticiones o la rentabilidad que se le debe exigir. A través de la experiencia de 10 años en BTE pretendemos revisar que puede aportarse a la realización de la prueba y a sus indicaciones. MÉTODO: Se han recogido los datos de PSA, características ecográficas y anatomía patológica de 6000 pacientes a los que se realizó BTE sextante modificada desde 1994 a diciembre de 2002.Para estudiar el papel de la biopsia ampliada se realizo un grupo experimental de 222 pacientes en los que se intentó la obtención de 10 muestras prostáticas mediante BTE. Para determinar la rentabilidad de la biopsia ampliada se estudiará la aportación de las muestras “extras” al rendimiento diagnóstico del grupo experimental (BTE ampliada) y se empleará como grupo control (BTE sextante) y de comparación un conjunto más amplio de 552 pacientes biopsiados en el año 2002. Se estudió la comparabilidad del grupo experimental y control, respecto a las variables recogidas al inicio del estudio. RESULTADOS: La incidencia de CP en el grupo de 6000 pacientes en la primera biopsia es del 39,1% (2345/6000). Los pacientes con PSA entre 4 y 10 ng/ml presentan una incidencia mayor del 50% de cánceres entre las próstatas de menos de 20 cc que disminuye hasta un 8,9% en la mayores de 50 cc. El porcentaje de CP entre los pacientes con PSA menor de 4ng/ml con tacto y ETR normales fue del 16,7%. La rentabilidad con Densidad de PSA menor de 0,11 ng/ml/c.c. fue inferior al 8%. El PSA L/T muestra una incidencia de CP del 13,7% con cifras superiores a 0,24. En las regresiones logísticas multivariantes únicamente el PSA L/T no resultó significativo. Entre los pacientes a los que se realizó BTE ampliada 60 (27,15%) presentaron CP. Tan sólo el 2,25% del total de 221 pacientes se beneficiaron del mayor número de muestras. No se han encontrado diferencias significativas en las cifras de CP entre los grupos de biopsia sextante y ampliada. En el análisis de regresión logística multivariante únicamente el PSA y el volumen han resultado significativos, careciendo de influencia en la detección de cáncer el número de muestras, la DPSA y la edad. CONCLUSIONES: El modelo sextante con obtención de muestras de los cuernos laterales de la próstata sigue siendo la referencia de la BTE mientras que la BTE ampliada no es aplicable de inicio a todos los pacientes por el escaso incremento en la capacidad diagnóstica. El PSA aislado no puede ser más el referente único para indicar la BTE, siendo, en nuestra experiencia, el volumen un factor decisivo para el ajuste de los niveles de mayor riesgo

OBJECTIVES: Although transrectal ultrasound- guided (TRUS) prostatic biopsy is the procedure of choice for the diagnosis of prostate cancer (PC), neither the ideal number of cores nor the number of repeated biopsies, nor the required diagnostic yield have been established. After our experience of ten years with TRUS biopsy we perform a review of the technique and its indications. METHODS: PSA, ultrasound features, and pathologic data of 6000 patients undergoing modified sextant TRUS biopsy between 1994 to December 2002 were collected. 222 patients undergoing ten-core TRUS biopsy were included in an experimental group to study the role of the extended biopsy. The contribution of the extra cores to the diagnostic yield in the experimental group was studied to determine the effectiveness of the extended biopsy, using as a control group 552 patients undergoing sextant TRUS biopsy during 2002. Both groups were comparable for the study variables at the start of the study. RESULTS: The incidence of PC in the first biopsy in the group of 6000 patients was 39.1% (2345/6000). Patients with PSA between 4 and 10 ng/ml have an incidence of PC greater than 50% among prostates smaller than 20 cc, diminishing down to 8.9% in those greater than 50 cc. The percentage of PC among patients with negative digital rectal examination (DRE), normal TRUS, and PSA below 4 ng/ml was 16.7%. The diagnostic yield for PSA density lower than 0.11 ng/ml/cc was lower than 8%. The free/total PSA ratio shows a 13.7% incidence of PC with values higher than 0.24. Multivariate logistic regression analysis showed that the only non-significant parameter was free/total PSA. Sixty (27.15%) patients of the extended TRUS biopsy group had PC. Only 2.25% of the 221 patients benefited from the augmented number of biopsies. There were no significant differences in the figures of prostate cancer between groups. Only PSA and volume where significant in the multivariate logistic regression analysis; number of samples, PSA density and age lacked of influence in the detection of PC. CONCLUSIONS: The sextant biopsy model obtaining cores from the lateral horns of the prostate continues to be the reference for TRUS biopsy, and the extended biopsy is not applicable to all patients from the beginning do to the small increase in the diagnostic yield. Isolated PSA may not be the unique reference to indicate TRUS biopsy, being volume, in our experience, a definitive factor for the adjustment of high risk levels

Papel de la ecografía transrectal en crioterapia y braquiterapia prostáticas / The role of transrectal ultrasound on prostatic cryotherapy and brachytherapy

OBJETIVO La ecografía transrectal es el método que proporciona una imagen directa de la próstata, sus límites, alteraciones estructurales y morfológicas y relaciones anatómicas. El volumen prostático es, en consecuencia, fácil de determinar, siendo el primer paso necesario para la aplicación de determinados procedimientos terapéuticos. La crioterapia y la braquiterapia prostáticas se han desarrollado en los últimos años como opciones mínimamente invasivas para el tratamiento del cáncer de próstata. La ecografía transrectal de próstata ha permitido la aplicación de estas tecnologías en la práctica diaria garantizando altos índices de eficacia y seguridad. La criocirugía es la congelación controlada de los tejidos. La ecografía transrectal de próstata es el único método capaz de reflejar en tiempo real la evolución de la crioablación prostática, permitiendo al urólogo controlar la evolución de la bola de hielo y alcanzar las estructuras anatómicas deseadas garantizando los objetivos oncológicos y disminuyendo la aparición de complicaciones y secuelas. La braquiterapia como forma de radioterapia local intraprostática necesita de cálculos volumétricos y dosimétricos exactos previos a la implantación de la fuente radioactiva en el interior de la glándula. Con ecografía transrectal de próstata se realizan cortes ecotomográficos para el cálculo del volumen y planimetría prostáticos. Una vez realizada la dosimetría y para realizar el implante de las agujas cargadas con las semillas en su lugar exacto es necesario el control con ecografía transrectal en tiempo real. Hoy en día la crioterapia y braquiterapia prostáticas serían inconcebibles sin la ecografía transrectal

OBJECTIVES: Transrectal ultrasound is the method that gives a direct image of the prostate, its limits, structural and morphologic anomalies, and anatomical relations. Therefore, prostate volume is easily determined, being the first step for the application of certain therapeutic procedures. Prostatic cryotherapy and brachytherapy have been developed over the last years as minimally invasive options for the treatment of prostate cancer. Transrectal ultrasound of the prostate has allowed the application of these technologies in the daily practice, guaranteeing high efficacy and safety indexes. Cryosurgery is the controlled freezing of tissues. Prostatic transrectal ultrasound is the only method able to show the real-time evolution of prostatic cryoablation, allowing the urologist to control the evolution of the ice ball and to reach the targeted anatomical structures guaranteeing the oncological objectives, and diminishing complications and sequels. Brachytherapy, as a local intraprostatic radiotherapy, needs exact volume and dose calculations before the implant of the radioactive source within the gland. With transrectal ultrasound of the prostate, ultrasound-tomographic cuts are made for prostatic volume calculation and planimetry. Once dosimetry is completed, real-time transrectal ultrasound control is necessary to perform the implant of the needles loaded with the seeds. Today, prostate cryotherapy and brachytherapy would be inconceivable without transrectal ultrasound

Ecografía testicular / No disponible

OBJETIVO: Se pretende revisar la aportación de la ecografía al diagnóstico diferencial de la patología escrotal tanto testicular como anexial. MÉTODO: se ha realizado una revisión bibliográfica sobre el tema incorporando la experiencia de nuestra Unidad a lo largo de los años, clasificando la patología en testicular y extratesticular y dentro de estas separando aquellas lesiones líquidas de las sólidas, además de un grupo de miscelánea no clasificable. RESULTADOS: actualmente la ecografía con equipos de alta frecuencia permite no sólo diferenciar entre patología intra y extraescrotal sino identificar lesiones específicas cuyo manejo puede incluir el seguimiento sin tener que recurrir a la exploración quirúrgica inevitable. CONCLUSIONES: la ecografía es una prueba sencilla, no dolorosa y puede repetirse sin mayor inconveniente por lo que es la primera prueba que debe solicitarse ante cualquier problema del contenido escrotal

OBJECTIVES: To review the contribution of ultrasound to the differential diagnosis of scrotal pathology, both testicular and adnexal. METHODS: We performed a bibliographic review on the topic, adding the experience of our Unit over the years; we classified the pathology in testicular and extratesticular, separating liquid and solid lesions, and a miscellaneous group of unclassifiable cases. RESULTS: Currently, ultrasonography with high frequency equipment allows not only to differentiate between intra and extratesticular lesions, but also to identify specific lesions, the manage of which may include follow-up without need of unavoidable surgery. CONCLUSIONS: Ultrasonography is a painless simple test that may be repeated without inconvenience so that it is the first test to be indicated for any problem of the scrotal content

[Diagnostic yield of the extended prostatic biopsy with 10 cores. Prospective study on 222 patients]. / Rentabilidad de la biopsia ampliada con 10 muestras prostáticas. estudio prospectivo sobre 222 pacientes.

OBJECTIVES: The number of biopsy samples for a proper prostate cancer diagnosis has not yet been established. We report our experience with the 10-sample extended biopsy. METHODS: We collected the results of a group of 222 patients undergoing extended ultrasound guided prostate biopsy with 10 samples. In addition to the sextant biopsies 2 extra samples were obtained from the dorsal-apex area on each lobe. Results of this group were compared with a control group of 552 patients undergoing sextant biopsy in 2002 with the same inclusion in criteria. RESULTS: 60 patients had cancer (27.15%). The extra samples gave the diagnosis in 5 out of 60 patients, 8.33% of the tumors and 2.25% of all patients. Control group showed cancer in 24.5%, not having the difference statistical significance. The incidence in prostates smaller than 20 cc was 69.2%, 11.6% in prostates bigger than 50 cc. 80% of the patients with prostate cancer only in the extra samples have a volume smaller than 35 cc. Multivariate logistic regression study for the probability of prostate cancer only showed association with serum PSA and prostate volume but not with the number of samples. CONCLUSIONS: The extended biopsy is not indicated as an initial diagnostic technique, being reserved for specific cases such as repeated biopsies in patients with high risk pathology reports. Neither it is indicated in the bigger volume prostates.

Rentabilidad de la biopsia ampliada con 10 muestras prostáticas. Estudio prospectivo sobre 222 pacientes / Diagnostic yield of the extended prostatic biopsy with 10 cores. Prospective study on 222 patients

OBJETIVO: Actualmente no está establecidoni el número de muestras ni de biopsias para el correcto diagnóstico del cáncer prostático. Presentamos nuestra experiencia en biopsia ampliada con 10 muestras.MÉTODO: se recogieron los resultados de un grupo de 222 pacientes en los que se realizó biopsia transrectal ecodirigida prostática ampliada con 10 muestras. Ademásde las muestras de una biopsia sextante se obtuvieron2 muestras “extras” de la región apical-dorsal de cada lóbulo, estudiando los resultados en este grupo y comparándolo con un grupo control de 552 pacientes sometidos en 2002 a biopsia sextante con los mismos criterios de inclusión.RESULTADOS: Presentaron cáncer 60 pacientes (27,15%). Las muestras “extras” supusieron el diagnósticoen 5 de los 60 pacientes, el 8,33% de los tumores y el 2,25% del total de pacientes. El grupo de control presentabacáncer en un 24,5% no resultando significativa la diferencia. Mientras que la incidencia en próstatas menores de 20 cc fue del 69,2% en las mayores de 50cc fue del 11,6%. De los pacientes diagnosticados únicamente por las muestras “extras” el 80% tenía un volumen menor de 35cc. En el estudio de regresión logísticamultivariante sólo se asoció con la posibilidad de cáncer el PSA sérico y el volumen prostático pero no el número de muestras.CONCLUSIÓN: la biopsia ampliada no está indicada como técnica diagnóstica de inicio debiendo reservarsepara casos concretos como rebiopsias en pacientes con anatomías patológicas de alto riesgo. Tampoco parece indicada en la biopsia de próstatas de mayor tamaño

OBJECTIVES: The number of biopsy samples for a proper prostate cancer diagnosis has not yet been established. We report our experience with the10-sample extended biopsy.METHODS: We collected the results of a group of 222 patients undergoing extended ultrasound guided prostate biopsy with 10 samples. In addition to the sextant biopsies 2 extra samples were obtained from the dorsal-apex area on each lobe. Results of this group were compared with a control group of 552 patients undergoing sextant biopsy in 2002 with the same inclusion in criteria.RESULTS: 60 patients had cancer (27.15%). The extra samples gave the diagnosis in 5 out of 60 patients, 8.33% of the tumors and 2.25% of all patients. Control group showed cancer in 24.5%, not having the difference statistical significance. The incidence in prostates smaller than 20 cc was 69.2%, 11.6% in prostates bigger than 50 cc. 80% of the patients with prostate cancer only in the extra samples have a volume smaller than 35 cc. Multivariate logistic regression study for the probability of prostate cancer only showed association with serum PSA and prostate volume but not with the number of samples.CONCLUSIONS: The extended biopsy is not indicated as an initial diagnostic technique, being reserved for specific cases such as repeated biopsies in patients with high risk pathology reports. Neither it is indicated in the bigger volume prostates

Tolerancia y complicaciones de la biopsia transrectal ecodirigida prostática ampliada a diez cilindros. Papel del bloqueo de haces neurovasculares con lidocaína / Tolerability and complications of the ultrasound guided transrectal biopsy of the prostate extended to 10 cores. The role of neurovascular bundle blockage with lidocaine

OBJETIVO: El creciente interés por ampliar el número de muestras obtenidas durante la biopsia transrectal ecodirigida prostática nos ha hecho evaluar la tolerancia y complicaciones de la biopsia ampliada con y sin bloqueo de los haces neurovasculares de esta modalidad diagnóstica.MÉTODO: Un grupo de 222 pacientes se sometieron a biopsia prostática con intención de obtener 10 cilindrosde tejido. Tras la evaluación de los primeros 50 pacientes realizados sin anestesia se decidió continuar practicando bloqueo de los haces neurovasculares con lidocaina al 2%, evaluando comparativamente los resultadosde tolerancia en ambos grupos y la incidencia de complicaciones y efectos secundarios en su conjunto.RESULTADOS: No se pudo completar el número de muestras previsto en el 16% de pacientes sin anestesia frente al 2,33% con anestesia (p<0,002), la prueba resultó dolorosa o muy dolorosa en el 10,9 y 1,9% respectivamente(p<0,0002). La puntuación en la escala analógica visual de dolor fue de 2,46± 1,67 y 4,5± 2,11 según se hubiera usado anestésico o no con reaccionesvagales leves-moderadas en el 28% de estos últimos frente al 7,7% si se administró lidocaina. La rectorragiafue la complicación más preocupante siendo moderada-importante en el 4,7% precisando de ingreso en un 2% de pacientes.CONCLUSIONES: El incremento del número de muestrasen la biopsia transrectal ecodirigida se puede asociara una mayor frecuencia de complicaciones sobre todo hemorrágicas y precisa de la aplicación de anestesialocal por su peor tolerancia, si bien el bloqueo de haces neurovasculares con lidocaina es muy efectivo parra disminuir el dolor asociado a las punciones

OBJECTIVES: The growing interest on increasing the number of biopsy samples during ultrasound guided prostatic biopsies moved us to evaluate the tolerability and complications of the extensive biopsy with/without blockage of neurovascular bundles. METHODS: A group of 222 patients underwent prostatic biopsy with the aim to obtain 10 cores on each. After evaluation of the first 50 cases performed without anesthesia, decision was taken to proceed with neurovascular blockage with 2% lidocaine, comparatively evaluating both groups for results on tolerability, complications and global adverse events. RESULTS: The aimed number of cores could not be completed in 16% of the patients without anesthesia in comparison with 2.33% with anesthesia (p < 0.002); the biopsy was qualified as painful or very painful by 10.9% and 1.9% respectively (p < 0. 0002). The results of the visual analogical scale for pain were 2.46 ± 1.67 and 4.5 ± 2.11 for the anesthesia / without anesthesia groups respectively, with mild-moderate vagal reactions in 28% of these latter in comparison with 7.7% in patients receiving lidocaine. Rectal bleeding was the most worrying complication, being moderate-severe in 4.7% of the patients, with 2% hospital admission. CONCLUSIONS: The increase in the number of ultrasound guided prostatic biopsy samples may be associated with a higher frequency of complications, mainly bleeding, and requires the application of local anesthesia due to worse tolerance. Neurovascular bundle blockage with lidocaine is very effective to diminish biopsy associated pain

Criocirugía (Tercera parte). Revisión de la literatura y nuestra experiencia. (II) / Cryotherapy III, bibliographic review. Our experience (II)

Resumen

OBJECTIVES: To perform a bibliographic review of the main features of cryotherapy as a therapeutic option in the managemente of prostate cancer and to report our initial experience.METHODS: We employed the Endocare Fast-Trac system (Medipro) with 2,4 mm needles implanted in a single maneouvre without rack or transrectal US transducersupport. Two cycles of freezing -thawing were employed, with apex backward movement when necessary. Freezing cycle duration was between 7-10 minutes or more. The Onik maneouvre – injection of saline into the Denonvillier’s space-diminishes the risk of rectal injury and fistula allowing reaching posterior limits of the icaball beyond the prostatic capsule.RESULTS: We treated 20 patients. Follow-up wasbetween 30-36 months. 58% of the patients had unilateral prostate cancer, 42% bilateral. In accordance to the classic definition 9 patients were classified as low risk of extraprostatic disease, 6 medium risk and 5 high risk; using number of positive cores as the criterion for risk 5, 6 and 9 were low, medium and high risk respectively. Per protocol prostate biopsies were performed in 18 patients 6, 12 and 24 months after treatment. Twopatients underwent a second treatment due to persistence of cancer cells in the 6-month biopsy (11%).3-month PSA nadirs after a total of 21 cryo treatments administered were < 0,2 ng/cc in 15 cases (78,9%), < 0,5 ng/cc in 17 (89,4%) and <= 1.0ng/cc in 18 (94,7%); it was over 1 ng/cc in only 5,6% . 30 month PSA for the same cutoff values was 27.8%, 50.0%, 66.6% and 33.3%, respectively.Prostate cancer cells were detected in the 12-month biopsies of 5.5% cases. All 24-month biopsies were negative.COMPLICATIONS: We observed scrotal edema, hematoma, perineal pain and constipation which lasted 2-3 weeks. 1 patient suffered injury of the mucosa at the prostatic urethra, which did not result in rectal fistula and was treated with bladder catheter for 3 months. 4 patients had erectile dysfunction before treatment. All others presented erectile dysfunction after treatment; 3 of them (20%) recovered rigidity enough to have intercourse over the 30 month period.No urethral sloughing or acute urinary retention appeared and all patients are continent.CONCLUSIONS: Prostatic cryosurgery is an effective, minimally invasive procedure for the treatment of prostate cancer with very low surgical risk, low morbidity and almost null mortality

[Results of a series of transrectal ultrasound guided biopsy of the prostate in 6000 patients. Part I: pathology, digital rectal examination, transrectal ultrasound, and PSA]. / Resultados de una serie de 6000 pacientes con biopsia transrectal ecodirigida de próstata. Parte I: anatomía patológica, tacto rectal, ecografía transrectal y psa.

OBJECTIVES: To analyze the results of transrectal ultrasound (TRUS) guided biopsy of the prostate in 6000 patients, and their relation to common-use clinical parameters. METHODS: We collected PSA, digital rectal examination, TRUS characteristics, and pathology report in a data- base including 6000 patients who underwent sextant TRUS biopsy from 1994 to December 2002. 861 of them underwent more than one biopsy, accounting for a total of 7127 biopsies. Sextant biopsy with samples from the most lateral portions of the prostate was the standard procedure so that they included peripheral zone only. We analyze pathological results and their relation with clinical variables. RESULTS: Total percentage of cancer in biopsy samples was 42.6%, with 39.1% in the first biopsy. Overall, repeated biopsies resulted in a 3.5% diagnostic yield increase. PIN or focal glandular atypia were detected in 2.0% and 2.1% of the cases respectively. The percentage of patients with Gleason score =<6 increased from 41.8% in the first biopsy to 70% in the third. Similarly, single core involvement increased from 21.% to 65%. Digital rectal examination and presence of hypoechogenic nodules specificity were 82.6 and 78.2% respectively. The incidence of prostate cancer with PSA between 4 and 10 ng/ml was 29.6%, 16.7% in those with PSA lower than 4 ng/ml. CONCLUSIONS: TRUS biopsy of the lateral prostatic areas offers a good diagnostic yield in comparison with most series of extensive biopsies. The sensitivity of TRUS has decreased but it maintains a high specificity which should not be forgotten when planning the TRUS strategy

[Results of a series of transrectal ultrasound guided biopsy of the prostate in 6000 patients. Part II: PSA derived parameters]. / Resultados de una serie de 6000 pacientes con biopsia transrectal ecodirigida de prostata. Parte II: parámetros derivados del PSA.

OBJECTIVES: We review the results of 6000 patients with the clinical suspect of prostate cancer who underwent one or more prostate, biopsies, analyzing the role of PSA derived parameters in the probability of having prostate cancer in the TRUS biopsy. METHODS: We selected 6000 patients who under- went TRUS biopsy between 1994 and 2002. 861 of them underwent more than one is biopsy, adding up to a total of 7127 biopsies. For the study of PSA derived indexes we established ranges based on the 10th percentile for the first biopsy for all patients and also for those with PSA between 4 and 10 ng/ml. Several predictive models were determined by logistic regression of the variables related with presence/no presence of cancer. RESULTS: For first biopsies the ranges of PSAD established showed a diagnostic effectiveness below 8% with PSA densities lower than 0.11 ng/ml/cc. The free/total PSA ratio is less discriminant in the ranges obtained with a 13.7% incidence of prostate cancer for values above 0.24. In the case of second biopsies the group of patients with PSAD below 0.12 had only a 5.3% incidence, and only one patient with F/T PSA ratio higher than 0.24 had a prostate cancer (2.9%). All studied parameters but F/T PSA ratio showed statistical significance in the multivariant analysis. CONCLUSIONS: Although the establishment of a cut point for PSAD diminishes sensitivity, prostate biopsy habits should be modified assuming the loss of tumors in patients with low PSAD and increasing the number of biopsies in patients with total PSA values below 4 ng/ml with higher densities.

Criocirugía (tercera parte). Revisión de la literature y nuestra experiencia. (I) / Cryotherapy III, bibliographic review. Our experience (I)

OBJETIVOS La criocirugía es una técnica verdaderamente mini-invasiva, eficaz para tratar el adenocarcinoma de próstata con riesgo quirúrgico escaso, nula mortalidad per y postoperatoria y sin apenas morbilidad. Ya se ha constatado que se puede aplicar a enfermos de alto riesgo quirúrgico. No precisa sangre ni UVI y es factible en pacientes con desórdenes de la coagulación y en quienes no consienten en recibir transfusiones. Los resultados -valorando niveles sanguíneos de PSA y biopsia negativa- se consolidan con el paso del tiempo. No causa interferencia sobre la eficacia de otras técnicas utilizables cuando no es efectiva. Sus fracasos se pueden recuperar además de con una segunda criocirugía, con prostatectomía radical; muy poco investigado con radioterapia externa y por supuesto mediante supresión androgénica. La crioterapia se puede aplicar con posibilidades de éxito en enfermos con cáncer extracapsular (T3) y la citotoxicidad del frío se ejerce eficazmente sobre: células pobremente diferenciadas y Gleason de 7 a 10; células resistentes o cáncer recidivado tras la radioterapia y el tratamiento previo con hormonoterapia no interfiere su efecto. Hay datos suficientes que apoyan las indicaciones que exponemos a continuación. 1.- Sería el tratamiento idóneo para realizar de 1ª intención. a) En pacientes con riesgo alto y medio de infiltración extracapsular. Son pocos los urólogos que indican la Prostatectomía radical en este grupo. Hay argumentos suficientes para anteponer la congelación controlada a la asociación braqui-radioterapia externa. Si consideramos persistencia de cáncer en la biopsia, elevación del PSA, complicaciones y peligrosidad de las mismas, se refieren muy buenos resultados. ¿Por qué ensayar la radiación y rescatar sus fracasos con crioterapia? Cuando la congelación se aplica como primera opción la tasa de éxitos mejora con respecto a la referida en cánceres resistentes o recidivados tras la radiación. Es evidente que las complicaciones serias son más graves y más frecuentes en pacientes previamente radiados y que no tienen fácil solución. b) En enfermos con cáncer limitado a la glándula con riesgo bajo de extensión extracapsular patologías múltiples y/o cuya edad biológica aparente ser superior a 70 años. c) En pacientes de bajísimo riesgo -PSA < 10, cáncer estadio T1c-T2a y Gleason 2-4 e incluso 5- incluidos los de expectativa de vida superior a 10 años que no se conforman con la pauta "vigilancia". 2.- Se debe considerar como alternativa a cirugía en casos con cáncer intraprostático, bajo riesgo de extensión extracapsular, edad no superior a 70 años y sin patología asociada; claros candidatos a la prostatectomía radical. Este grupo sería bueno para hacer un estudio comparativo y valorar: eficacia, complicaciones, calidad de vida y relación costo-beneficio. Los efectos secundarios más temibles prácticamente han desaparecido: la fístula uretro-rectal, utilizando la maniobra de Onik y las uretro-cutáneas ni se mencionan. Con el empleo del sistema protector de uretra aprobado por la FDA y control de la temperatura en el esfínter estriado, desciende el riesgo de obstrucción y la necesidad de RTUs o manipulaciones endoscopias para extraer esfacelos. No se refiere incontinencia en más del 2% de los casos. También ahorra días de ingreso: 1,5 de media. No precisa UVI ni transfusión. 3.- Pacientes con cáncer resistente o recidivante tras Braquiterapia y/o Radioterapia externa. La Braquiterapia es inapropiada en esta situación: el Gleason es más alto que el primitivo en 2 de cada 3 casos y muchos tienen extensión extracapsular. De suma importancia el efecto "recuerdo de radiación": el tejido normal sólo tolera una dosis determinada incluso transcurridos varios años. Son mejores opciones la prostatectomía radical y la congelación controlada. Para prevenir la progresión local y su morbilidad asociada, para tratar de controlar el cáncer resistente a la radiación y evitar la diseminación a distancia a partir de la recidiva, se recurre a la prostatectomía radical; cirugía la mayoría de las veces bastante compleja. Para conseguir dichos objetivos preferimos la crioterapia. Con menos riesgo quirúrgico sin transfusión ni UVI, menor gravedad y número de complicaciones se describen resultados similares en cuanto al control del cáncer se refiere. 4.- En pacientes con cáncer unilateral, unifocal y bajísimo o bajo riesgo de extensión extracapsular, es posible evitar la impotencia aplicando la técnica de congelación focal.HORMONOTERAPIA PREVIA: Debe indicarse sólo con la finalidad de reducir el volumen prostático al límite más idóneo (menor de 40 - 50 cc). Ventajas que proporciona: la glándula admite una congelación más rápida, precisa menos cantidad de gas, se mitiga la dificultad que entraña la interferencia del pubis y facilita la distribución espacial del menor número de sondas requerido. Todo ello, mejora la dosificación del frío y elimina gradientes de temperaturas acusados en los tejidos interpuestos entre cada dos elementos contiguos. NUESTRA EXPERIENCIA: Emplear dilatadores, es ya historia. Nosotros hemos usado el sistema Fast-Trac de Endocare (Medipro): sondas de 2,4 mm de diámetro implantadas con una sola maniobra sin la ayuda de rejilla ni dispositivo de soporte para el transductor transrectal. Dos ciclos congelación - deshielo con retroceso apical en caso necesario. Duración de la congelación por ciclo entre 7 y 10 minutos e incluso más sin poner en riesgo la pared del recto. Permitiendo que el límite ecográfico de la congelación sobrepase la cápsula prostática incluso por su cara posterior: la maniobra de Onik -inyección de suero salino en el espacio de Denonvilliers´- permite congelar con garantías más alla del límite posterior de la glándula sin incrementar el riesgo de fístula. RESULTADOS Hemos tratado 20 enfermos y seguido entre 30 y 36 meses. A partir del porcentaje de cilindros afectados y de su localización se han etiquetado de unilaterales el 58% y de bilaterales el 42% y atendiendo a la definición clásica son de riesgo bajo 9 enfermos, medio 6 y alto 5 y añadiendo la proporción de cilindros afectados 5, 6 y 9 respectivamente. Se ha practicado biopsia a 18 pacientes realizada por sistema en los meses 6, 12 y 24. Dos enfermos han sido recuperados con una segunda sesión por persistir cáncer en la biopsia obtenida a los 6 meses (11%). Con 21 criocirugías administradas a 19 enfermos, alcanzaron a los 3 meses nadir inferior a 0,2 ng/cc; a 0,5 ng/cc e igual o inferior a 1,0 ng/cc, 15 (78,9%); 17 (89,4%) y 18 (94,7%) respectivamente y sólo en el 5,26% fue superior a 1,0 ng/cc. La proporción de PSA a los 30 meses para esos mismos cortes y por el mismo orden es del 27,8%; 50%; 66,6% y 33,3%. De los 18 biopsiados se objetivó cáncer a los 12 meses en el 5,5%. Y no fue positiva ninguna de las biopsias realizadas en 17 pacientes a los 24 meses. Complicaciones, hemos observado edema de escroto, hematoma, dolor perineal y estreñimiento que remitieron en el transcurso de 2 - 3 semanas. Lesión del urotelio prostático, sin llegar a ser fístula uretro-rectal, en 1, curada con sonda permanente durante 3 meses. Cuatro enfermos -con disfunción eréctil antes de la congelación- continúan sin erecciones. De los otros 15, todos impotentes después de la criocirugía, 3 (20%) han recuperado turgencia suficiente para realizar el coito a lo largo de los 30 meses. Todos los enfermos contienen la orina y en ningún caso hemos observado eliminación de esfacelos ni retención urinaria

OBJECTIVES: To perform a bibliographic review of the main features of cryotherapy as a therapeutic option in the managemente of prostate cancer and to report our initial experience.METHODS: We employed the Endocare Fast-Trac system (Medipro) with 2,4 mm needles implanted in a single maneouvre without rack or transrectal US transducer support. Two cycles of freezing -hawing were employed,with apex backward movement when necessary. Freezing cycle duration was between 7-10 minutes or more. The Onik maneouvre – injection of saline into the Denonvillier’s space—diminishes the risk of rectal injury and fistula allowing reaching posterior limits of the icaballbeyond the prostatic capsule.RESULTS: We treated 20 patients. Follow-up was between 30-36 months. 58% of the patients had unilateral prostate cancer, 42% bilateral. In accordance to the classicdefinition 9 patients were classified as low risk of extraprostaticdisease, 6 medium risk and 5 high risk; using number of positive cores as the criterion for risk 5, 6 and 9 were low, medium and high risk respectively. Perprotocol prostate biopsies were performed in18 patients 6, 12 and 24 months after treatment. Two patientsunderwent a second treatment due to persistence ofcancer cells in the 6-month biopsy (11%).3-month PSA nadirs after a total of 21 cryo treatments administered were < 0,2 ng/cc in 15 cases (78,9%), < 0,5 ng/cc in 17 (89,4%) and <= 1.0ng/cc in 18 (94,7%); it was over 1 ng/cc in only 5,6%. 30 month PSA for the same cutoff values was 27.8%, 50.0%, 66.6% and 33.3%, respectively.Prostate cancer cells were detected in the 12-month biopsies of 5.5% cases. All 24-month biopsies were negative.COMPLICATIONS: we observed scrotal edema,hematoma, perineal pain and constipation which lasted 2-3 weeks. 1 patient suffered injury of the mucosa at the prostatic urethra, which did not result in rectal fistula and was treated with bladder catheter for 3 months. 4 patients had erectile dysfunction before treatment. All others presented erectile dysfunction after treatment; 3 of them (20%) recovered rigidity enough to have intercourse over the 30 month period.No urethral sloughing or acute urinary retention appeared and all patients are continent.CONCLUSIONS: Prostatic cryosurgery is an effective, minimally invasive procedure for the treatment of prostate cancer with very low surgical risk, low morbidity and almost null mortality

Papel del volumen prostático en la biopsia transrectal ecodirigida de próstata: ¿es un marcador tan importante como el PSA? / The role of prostate volume in ultrasound guided transrectal prostate biopsy: is it as important as a marker as PSA?

OBJETIVO: La limitación del PSA paraidentificar a los pacientes con cáncer prostático hahecho que se definan diferentes parámetros que aumentensu especificidad sin reducir su sensibilidad de formaimportante. En este trabajo se estudia la relación delvolumen con la presencia de cáncer de próstata enbiopsia sextante.MÉTODO: se han recogido los resultados de las biopsiasprostáticas realizadas a 6000 pacientes entre1994 y 2002. De ellos 861 se han biopsiado en másde una ocasión, sumando un total de 7127 biopsias.Se realizaron diferentes modelos predictivos para identificarlos factores relacionados con la positividad de labiopsia. RESULTADOS: La media de volumen prostático es de40,6± 66,2 c.c. en la primera biopsia aumentando enlas sucesivas biopsias hasta los 85,17 c.c. Se observauna alta incidencia de CP en las próstatas pequeñasque alcanza el 67,2% en las de tamaño normal (menoresde 20 c.c.) que disminuye a medida que aumentael volumen encontrando únicamente un 19,7% en aquellasmayores de 50 c.c. (p<0,0001). En pacientes conPSA entre 4 y 10 ng/ml y segundas biopsias el porcentajede cáncer con glándulas mayores de 50cc fueinferior al 10%. En la regresión logística multivariantemostraron relación con la positividad el PSA, el volumeny la Densidad de PSA pero no la relación PSALibre/PSA total.CONCLUSIONES: Los puntos de corte estándar dePSA no son adecuados para un correcto diagnósticode CP mediante BTE. El volumen (HPB) influye de maneradeterminante en sus cifras y en la rentabilidad de laprueba por lo que es preciso tenerlo en consideraciónal indicar la biopsia

OBJECTIVES: The limitations of PSA to identify patients with prostate cancer prompted the definition of different parameters trying to increase specificity without reducing sensitivity. This paper studies the relationship of volume and presence of prostate cancer in sextant biopsies. METHODS: We collected the results of prostate biopsies performed to 6000 patients between 1994 and 2002. 861 of them underwent more than one biopsy, adding up for a total of 7127 biopsies. Various predictive models to identify factors related to positive biopsy were constructed. RESULTS: Mean prostate volume is 14.6 ± 66.2 cc for the first biopsy, increasing in successive biopsies to 85.17 cc. A high incidence of prostate cancer was observed in small prostates, reaching 67.2% of those with normal size (< 20 cc) and diminishing with the increase of volume down to only 19.7% in those larger than 50 cc (p < 0.0001). In second biopsies of patients with PSA between 4 and 10 ng/ml and gland volume higher than 50 cc percentage of biopsies positive for cancer was below 10%. Multivariant logistic regression showed that PSA, volume and PSA density were related with positive biopsies, but not free/total PSA ratio. CONCLUSIONS: Standard PSA cutoffs are not adequate for a proper diagnosis of prostate cancer by ultrasound guided transrectal biopsy. Volume (BPH) has a significant influence in PSA values and results of the biopsy, so that it should be taken into consideration when indicating biopsies