A new ultrasound and clinical classification for management of prostatic abscess.

OBJECTIVES: In literature, most of the published data regarding prostatic abscess (PA) are case reports, whereas there is no standardization of the diagnostic and therapeutic routines. The purpose of this study is a new classification of ultrasound imaging of PA with clinical features correlation. MATERIAL AND METHODS: We retrospectively analysed the ultrasound database archives and performed a MEDLINE® research of the peer reviewed literature on diagnosis and case reports of PA using the terms "prostate and abscess". RESULTS: PA can be classified into five Types: Type I - PA is present focally in a prostate lobe (≤ 10 mm). Type II - PA is present in a prostate lobe (> 10 mm) and/or partially overcrosses the border of the midline prostatic glandular. Type III - PA is present in both glandular lobes form of multifocal areas (≤ 10 mm). Type IV - PA is present in both glandular lobes form of multifocal areas (> 10 mm). Type V - PA involving intra or extraprostatic structures (bladder, urethra, seminal vesicles and prostatic capsule). The different ultrasound imaging and diagnostic criteria are listed for each type and subtype. CONCLUSIONS: The sonographic pattern of PA is usually characteristic and easily differentiated from other glandular lesions. The purpose of the study was to associate the use of TRUS to a clinical standardized classification in order to facilitate PA diagnosis and localization directing the clinician treatment to the correct management and adequate therapeutic treatment.

Prevalence of prostatic calcification subtypes and association with prostate cancer.

OBJECTIVE: To evaluate the prevalence and to classify prostatic calcification on transrectal ultrasonography (TRUS) and correlate the findings with histology. METHODS: A prospective, blinded study of men undergoing TRUS and prostatic biopsy was designed. A standardized reproducible technique was used with a BK 7.5- to 12.5-MHz multiplanar probe. Representative images of the calcification in the sagittal and transverse planes were captured. Blind analysis by an experienced observer was performed. TRUS findings were categorized using a novel classification and correlated with histologic data. RESULTS: A total of 274 patients (58.8%) had prostate cancer, 88 patients (18.9%) inflammation, and 104 patients (22.3%) had benign pathology. Interface calcification was present in 42.3% of patients. Peripheral or transitional zone calcification was unusual (6.8% and 9.0%, respectively). Of the peripheral zone calcification group patients, 78.1% had cancer on histology examination (P = .020). CONCLUSION: Prevalence and characteristics of prostatic calcification have been described using this novel and practical classification. Although interface calcification is common and not associated with any particular pathology, peripheral zone calcification appears to be strongly associated with prostate cancer.

Focal prostatic atrophy: morphologic classification and immunohistochemistry.

OBJECTIVE: To describe the morphology of focal prostatic atrophy and propose a comprehensive histologic classification for a proper diagnostic recognition. STUDY DESIGN: A broad immunohistochemical study was performed as an adjunct to its recognition as well as a contribution to pathogenesis. RESULTS: A morphologic continuum was seen on needle biopsies. Chronic inflammation was present only in complete atrophy. Immunohistochemical findings in partial atrophy are similar to normal acini. Luminal compartment in complete atrophy shows aberrant expression of 34betaE12 favoring an intermediate phenotype. ERG negativity in all variants of atrophy may have value in the identification of the lesion. CONCLUSION: The morphologic findings favor a continuum probably partially preceding complete atrophy. Chronic inflammation may be a secondary phenomenon seen only in complete atrophy. Overexpression in complete atrophy of glutathione S-transferase pi relates to oxidative stress possibly related to chronic ischemia, of c-Met favors the concept that intermediate cells may be target for carcinogenesis, and of CD44 may be related to the recruitment of inflammatory cells.

El ultrasonido en la patología prostática benigna: actualización bibliográfica / Ultrasound in benign prostate pathology: bibliographic update

La evaluación de la próstata a través del ultrasonido puede realizarse vía transabdominal o transrectal. Esta revisión se centra en el uso de distintas técnicas para evaluar la hiperplasia prostática benigna, la presencia de quistes prostáticos y de las vesículas seminales, y la inflamación de la próstata.

El ultrasonido en la patología prostática benigna: actualización bibliográfica / Ultrasound in benign prostate pathology: bibliographic update

La evaluación de la próstata a través del ultrasonido puede realizarse vía transabdominal o transrectal. Esta revisión se centra en el uso de distintas técnicas para evaluar la hiperplasia prostática benigna, la presencia de quistes prostáticos y de las vesículas seminales, y la inflamación de la próstata.(AU)

Assessment of lower urinary tract symptoms in men by international prostate symptom score and core lower urinary tract symptom score.

UNLABELLED: Study Type - Therapy (symptom prevalence). Level of Evidence 2a. What's known on the subject? and What does the study add? The International Prostate Symptom Score (IPSS) has been most commonly used for the symptom assessment of men with lower urinary tract symptoms (LUTS). However, LUTS in men are so variable that they may not be fully captured by the IPSS questionnaire alone. This study has demonstrated that the Core Lower Urinary Tract Symptom Score (CLSS) questionnaire, which addresses 10 important symptoms, is an appropriate initial assessment tool for LUTS in men with various diseases/conditions. OBJECTIVE: International Prostate Symptom Score (IPSS) has been commonly used to assess lower urinary tract symptoms (LUTS). We have recently developed Core Lower Urinary Tract Symptom Score (CLSS). The aim of this study is to compare IPSS and CLSS for assessing LUTS in men. PATIENTS AND METHODS: Consecutive 515 men fulfilled IPSS and CLSS questionnaires. IPSS QOL Index was used as the QOL surrogate. The clinical diagnoses were BPH (n = 116), BPH with OAB wet (n =80), prostate cancer (n = 128), prostatitis (n = 68), underactive bladder (n = 8), others (n = 72), and controls (e.g., occult blood) (n = 42). Simple statistics and predictability of poor QOL (QOL Index 4 or greater) were examined. RESULTS: All symptom scores were significantly increased in symptomatic men compared with controls. Scores of corresponding symptoms of two questionnaires were significantly correlated (r = 0.58-0.85, all P < 0.0001). A multivariate regression model to predict poor QOL indicated nine symptoms (daytime frequency, nocturia, urgency, urgency incontinence, slow stream, straining, incomplete emptying, bladder pain and urethral pain) as independent factors. The hazard ratios for bladder pain (2.2) and urgency incontinence (2.0) were among the highest. All the nine symptoms are addressed in CLSS, while three symptoms (urgency incontinence, bladder, and urethral pain) are dismissed in IPSS. CONCLUSION: CLSS questionnaire is more comprehensive than IPSS questionnaire for symptom assessment of men with various diseases/conditions, although both questionnaires can capture LUTS with possible negative impact on QOL.

Association between metabolic syndrome and male lower urinary tract symptoms in Japanese subjects using three sets of criteria for metabolic syndrome and International Prostate Symptom Score.

OBJECTIVES: To investigate whether the metabolic syndrome is a risk factor for lower urinary tract symptoms (LUTS), as defined by the International Prostate Symptom Score (IPSS). METHODS: A total of 900 men underwent digital rectal examination of the prostate and completed an IPSS questionnaire. These men had visited our hospital for metabolic screening from April 2008 to March 2009. The IPSS includes scores for 3 questions on voiding symptoms, 3 on storage symptoms, and 1 on postmicturition symptoms. The relationships of the LUTS (determined from the IPSS subscores) with the metabolic syndrome diagnosed using the Japan Society for the Study of Obesity, 2005 National Cholesterol Education Program-Adult Treatment Panel III, and 2005 International Diabetes Federation criteria were examined. The severity of LUTS was compared among the younger, middle-age, and older men (<50, 50-64, and ≥65 years old, respectively) with and without the metabolic syndrome. RESULTS: A diagnosis of the metabolic syndrome was made in 16.7%, 16.6%, and 11.7% of the men using the Japan Society for the Study of Obesity, 2005 National Cholesterol Education Program-Adult Treatment Panel III, and 2005 International Diabetes Federation criteria, respectively. Regardless of the presence of the metabolic syndrome, aging was significantly associated with an increased rate of moderate or severe LUTS, except for postmicturition symptoms. In the middle-age men, the metabolic syndrome had a significant negative correlation with storage symptoms (odds ratio 0.258-0.426). In the younger and older men, LUTS was observed equally in those with and without the metabolic syndrome. CONCLUSIONS: A relationship between age and LUTS was observed; however, the metabolic syndrome did not show a clear association with LUTS. Our results suggest that LUTS is associated with aging, regardless of the presence of the metabolic syndrome.

Pseudoneoplastic mimics of prostate and bladder carcinomas.

CONTEXT: The differential diagnoses of prostatic carcinoma and bladder epithelial neoplasms include several histologic mimics that should be known to avoid misdiagnosis. OBJECTIVE: To discuss pseudoneoplastic lesions of the prostate and bladder that could potentially be confused with prostatic carcinoma and bladder epithelial neoplasms, respectively, with specific focus on their distinguishing histopathologic features. DATA SOURCES: Relevant published literature and authors' experience. CONCLUSIONS: Pseudoneoplastic lesions in the prostate include those of prostatic epithelial origin, the most common being atrophy, adenosis (atypical adenomatous hyperplasia), basal cell hyperplasia, and crowded benign glands, as well as those of nonprostatic origin, such as seminal vesicle epithelium. Such lesions often mimic lower-grade prostatic adenocarcinoma, whereas others, such as clear cell cribriform hyperplasia and granulomatous prostatitis, for example, are in the differential diagnosis of Gleason adenocarcinoma, Gleason grade 4 or 5. Pseudoneoplastic lesions of the urinary bladder include lesions that could potentially be confused with urothelial carcinoma in situ, such as reactive urothelial atypia, and others, such as polypoid/papillary cystitis, where papillary urothelial neoplasms are the main differential diagnostic concern. Several lesions can mimic invasive urothelial carcinoma, including pseudocarcinomatous hyperplasia, von Brunn nests, and nephrogenic adenoma. Diagnostic awareness of the salient histomorphologic and relevant immunohistochemical features of these prostatic and urinary bladder pseudoneoplasms is critical to avoid rendering false-positive diagnoses of malignancy.

Classification of prostatic diseases by means of multivariate analysis on in vivo proton MRSI and DCE-MRI data.

Multivariate analysis has been applied on proton magnetic resonance spectroscopic imaging ((1)H-MRSI) and dynamic contrast enhanced MRI (DCE-MRI) data of patients with different prostatic diseases such as chronic inflammation, fibrosis and adenocarcinoma. Multivariate analysis offers a global view of the entire range of information coming from both the imaging and spectroscopic side of NMR technology, leading to an integrated picture of the system relying upon the entire metabolic and dynamic profile of the studied samples. In this study, we show how this approach, applied to (1)H-MRSI/DCE-MRI results, allows us to differentiate among the various prostatic diseases in a non-invasive way with a 100% accuracy. These findings suggest that multivariate analysis of (1)H-MRSI/DCE-MRI can significantly improve the diagnostic accuracy for these pathological entities. From a more theoretical point of view, the complementation of a single biomarker approach with an integrated picture of the entire metabolic and dynamic profile allows for a more realistic appreciation of pathological entities.

New classification of midline cysts of the prostate in adults via a transrectal ultrasonography-guided opacification and dye-injection study.

OBJECTIVES: To reclassify midline cysts (MLCs) of the prostate according using the results from transrectal ultrasonography (TRUS)-guided opacification and dye injection. PATIENTS AND METHODS: Eighty-six patients (mean age 60.9 years) who had MLCs detected in the pelvis by TRUS were investigated. In all patients the size of the MLC was measured and they had transperineal aspiration under TRUS guidance. After aspiration of the MLC a mixture of water-soluble contrast medium and indigo carmine dye was injected to check for communication with the urethra or seminal tract by endoscopic and pelvic X-ray examination. RESULTS: We classified MLCs into four categories: (i) type 1 (nine cases), MLC with no communication into the urethra (traditional prostatic utricle cyst); (ii) type 2a (60 cases), MLC with communication into the urethra (cystic dilatation of the prostatic utricle, CDU); (iii) type 2b (14 cases), CDU which communicated with the seminal tract; (iv) type 3 (three cases), cystic dilation of the ejaculatory duct. The location, shape and volume of the MLC, and the prostate-specific antigen level of MLC fluid, did not influence the classification. CONCLUSIONS: The most common type of MLC was CDU. A new classification that depends on the communication with the urethra or seminal tract is proposed.

A working group classification of focal prostate atrophy lesions.

Focal atrophy is extremely common in prostate specimens. Although there are distinct histologic variants, the terminology is currently nonstandardized and no formal classification has been tested for interobserver reliability. This lack of standardization hampers the ability to study the biologic and clinical significance of these lesions. After informal and formal meetings by a number of the authors, focal atrophy lesions were categorized into 4 distinct subtypes as follows: (i) simple atrophy, (ii) simple atrophy with cyst formation, (iii) postatrophic hyperplasia, and (iv) partial atrophy. In phase 1 of the study, pathologists with varying levels of experience in prostate pathology were invited to view via the Internet a set of "training" images with associated descriptions of lesions considered typical of each subtype. In phase 2 of the study, each participant provided diagnoses on a series of 140 distinct "test" images that were viewed over the Internet. These test images consisted of the 4 subtypes of atrophy and images of normal epithelium, high grade prostatic intraepithelial neoplasia, and carcinoma. The diagnoses for each image from each pathologist were compared with a set of "standard" diagnoses and the kappa statistic was computed. Thirty-four pathologists completed both phases of the study. The interobserver reliability (median kappa) for classification of lesions as normal, cancer, prostatic intraepithelial neoplasia, or focal atrophy was 0.97. The median kappa for the classification of atrophy lesions into the 4 subtypes was 0.80. The median percent agreement with the standard diagnosis for the atrophy subtypes were: simple 60.6%, simple with cyst formation 100%; postatrophic hyperplasia 87.5%; partial atrophy 93.9%. The lower percentage for simple atrophy reflected a propensity to diagnose some of these as simple atrophy with cyst formation. Seven pathologists completed the phase 2 analysis a second time, and their intraobserver reproducibility was excellent. Three of 4 pathologists with low agreement with the standard diagnosis for simple atrophy improved their scores after repeating the analysis after re-examination of the "training set" of images. In conclusion, these criteria for variants of focal prostate atrophy may facilitate studies to examine the relation between various patterns of prostate atrophy and prostate cancer.

Classification of cystic structures located at the midline of the prostate: our experience.

OBJECTIVES: Between January 1994 and February 2002, 9086 men underwent biplane TRUS at our institution for a variety of reasons. 781 of the 9086 men (8.6%) showed evidence of one or more intraprostatic cystic lesions. We propose a new classification of cystic structures located at the midline of the prostate. MATERIAL AND METHODS: We have designed a methodology that reclassifies cystic structures located at the prostate midline through the ultrasonically guided transrectal aspiration of the cystic structure, the analysis of the PSA level of the aspirated fluid and the presence of spermatozoa, radiological studies (cyst injection with contrast medium, vasography, retrograde and/or voiding cystourethrography and utricle injection with contrast medium) and endoscopic studies (cystourethroscopy). RESULTS: Upon completion of the methodology, we have classified and defined these structures as the following: simple prostatic cysts, cysts of the müllerian ducts, megautricle, megautricle with inclusion of the ejaculatory ducts, "pseudocystic" dilation of the ejaculatory ducts and utriculoceles. CONCLUSIONS: This new classification of cystic structures located at the prostate midline is simple, useful and steers one away from any possible confusion.

Histopathological study of the müllerian duct remnant: clarification of disease categories and terminology.

PURPOSE: We determined by histopathological studies whether there is an etiological difference in 2 distinct categories of müllerian duct remnant diseases. In addition, we clarified the nomenclature of these diseases. MATERIALS AND METHODS: We recently performed radical prostatectomy in a patient with prostate cancer associated incidentally with a so-called müllerian duct cyst in the prostatic midline. The specimen was examined by pathological and immunohistochemical testing with special attention to the relationship of the cyst and utricle. We also investigated the histology of so-called enlarged prostatic utricles or vagina masculinus extirpated from patients with severe hypospadias or intersex disorder. RESULTS: The round cyst removed with the prostate seemed to arise from the verumontanum and it contained fluid with a high concentration of prostate specific antigen. Histological and immunohistochemical examination of its lining epithelium demonstrated that cyst characteristics were identical to those of the prostatic utricle. On the other hand, pouches extirpated from patients with pediatric problems were lined by squamous epithelium. CONCLUSIONS: The so-called müllerian duct cyst appeared to originate from the prostatic utricle, and so should be termed a utricular cyst or cystic utricle. Conversely the so-called enlarged prostatic utricle should be termed a vagina masculinus or male vagina. The term müllerian duct remnant, which would include these 2 abnormalities, may usefully be replaced by the term utricular abnormalities.

Novel approaches to the diagnostics and treatment of chronic prostatic diseases.

This article presents a modified technique for investigating the prostatic blood flow--rheoprostatography (impedance electroplethysmography of the prostate gland). It also gives some averaged rheographic parameters typical of most prevalent prostatic diseases (such as prostatitis, benign prostatic hyperplasia, and prostate cancer). These parameters were measured both under normal conditions and during functional tests. Furthermore, this article classifies prostatic blood-flow insufficiency into several stages. It is recommended that the combined therapy of chronic prostatic diseases should involve endorectal procedures of pulsed fluctuating stimulation (PFS), with rheographic monitoring being used as a feedback loop of such procedures.

[The pathological prostatic utricle: two case reports]. / L'utricule prostatique pathologique: à propos de 2 observations.

The prostatic utricle is a small vestigial diverticulum on the posterior surface of the prostatic urethra. It is considered to be pathological when it is abnormally dilated. The prostatic utricle is revealed by signs of vesical irritation and dysuria, sometimes associated with a retrovesical mass on examination. The authors report two cases of pathological prostatic utricle. The first case was an 11-year-old boy presenting with dysuria. Retrograde cystourethrography confirmed the diagnosis. The utricle was resected via a transtrigonal intravesical approach. The second case was a 25-year-old man who presented with dysuria associated with a pelvic mass. IVU and ultrasonography suggested a diagnosis of retrovesical cyst. This patient underwent incomplete resection of the utricle via a retrovesical approach. Based on a review of the literature, the authors emphasize the need to look for a prostatic utricle in a young subject presenting with dysuria, particularly in patients with a malformation of the genitourinary tract (hypospadias, renal agenesis). All pathological prostatic utricles must be treated surgically. The incision is transtrigonal in medium-sized utricles and transperitoneal in large utricles. The utricular cavity must be resected as completely as possible.