Initial extended transrectal prostate biopsy--are more prostate cancers detected with 18 cores than with 12 cores?

PURPOSE: We retrospectively investigated the detection rates of prostate cancer, high grade prostatic intraepithelial neoplasia and atypical glands suggestive of carcinoma by initial 18 and 12-core prostate biopsy. MATERIALS AND METHODS: A total of 3,460 consecutive patients with prostate specific antigen between 2.5 and 15 ng/ml underwent 12 (1,684) or 18 (1,776) core prostate biopsy under local anesthesia at 2 departments that adopted the same indications for performing biopsy. Biopsies were evenly distributed throughout the prostate in 6 sectors. In the 12-core prostate biopsy group 2 samples were obtained from each sector and in the 18-core prostate biopsy group 1 additional core was taken from each sector. RESULTS: The cancer detection rate in patients who underwent 18-core prostate biopsy was not different from the rate in those who underwent 12-core prostate biopsy (39.9% and 38.4%, p = 0.37), nor did the detection of atypical glands suggestive of carcinoma differ significantly between the 2 groups (2.9% and 3.3%, respectively, p = 0.33). However, 18-core prostate biopsy detected a significantly higher percent of cases of high grade prostatic intraepithelial neoplasia (20.0% vs 12.9%, p = 0.001). The cancer detection rate was higher with 18 than with 12-core prostate biopsy in patients with a prostate volume of 55 cc or greater (31.5% vs 24.8%, p = 0.01) but not in those with a prostate volume of less than 55 cc (54.3% and 53.0%, respectively, p = 0.7). Moreover, we determined that patients with positive digital rectal examination findings do not need 18-core prostate biopsy as opposed to 12-core prostate biopsy. CONCLUSIONS: Compared with 12-core prostate biopsy, 18-core prostate biopsy detects significantly more cases of high grade prostatic intraepithelial neoplasia. However, 18-core prostate biopsy detects a significantly higher number of cancer only in patients with a prostate volume of 55 cc or greater.

Safety and tolerability of oral erectile dysfunction treatments in the elderly.

Erectile dysfunction (ED) is a common medical condition that affects the sexual life of millions of men worldwide. It is generally accepted that sexual function tends to decline with aging, which is often associated with a higher prevalence of sexual problems, including ED and loss of libido. As the mean age of men seeking medical help for sexual dysfunction continues to increase, it is important to assess the safety and tolerability of currently available medical treatments in elderly men, who often share other co-morbidities that should be carefully evaluated when any type of ED therapy is considered. With this aim in mind, a MEDLINE search was conducted from 1 January 1998 to 31 May 2004 to identify studies assessing the efficacy, safety and tolerability of treatments for ED in the elderly. Particular care was taken to assess the cardiovascular safety of oral drugs for ED in this subset of patients, who often have multiple cardiovascular risk factors which contribute to a complicated clinical scenario. The most important conclusion of the paper is that the high efficacy, reliability, safety and tolerability of oral ED treatments makes them appropriate first-line therapies for elderly patients with ED.

Tissue-resonance interaction method for the noninvasive diagnosis of prostate cancer: analysis of a multicentre clinical evaluation.

OBJECTIVE: To determine, in a multicentre prospective study, the accuracy of the tissue-resonance interaction method (TRIMprob, new technology developed for the noninvasive analysis of electromagnetic anisotropy in biological tissues) in the diagnosis of prostate cancer. PATIENTS AND METHODS: Two hundred patients (mean age 67.4 years) scheduled to have prostatic biopsies (because of a prostate-specific, PSA, antigen level of >/=4 ng/mL or a suspicious digital rectal examination, DRE) were preliminarily examined while unaware of their clinical details using TRIMprob in five different centres. The final diagnosis obtained with TRIMprob was compared with the final histological diagnosis after extended biopsies. RESULTS: Of the 188 evaluable patients (mean PSA level 9.3 ng/mL, sd 8.8; mean prostate volume 62.0 mL, sd 32.4), 61 (32.4%) had a positive biopsy for adenocarcinoma of the prostate. The overall sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of TRIMprob were 80%, 51%, 44%, 84% and 60%, respectively. The prostate cancer detection rate after biopsy was significantly higher in patients with a positive examination (49/111, 44%) than in patients with a negative TRIMprob (12/77, 15%; P < 0.001). When TRIMprob results were combined with DRE findings the sensitivity and NPV both increased to 92%. CONCLUSION: TRIMprob seems to be a useful tool in the diagnosis of prostate cancer and can increase the accuracy of PSA or DRE results. The high NPV suggests that this new technology might be useful to reduce the indications for prostatic biopsy or repeated series of biopsies in patients suspected of having prostate cancer.

Holmium laser enucleation versus open prostatectomy for benign prostatic hyperplasia: an inpatient cost analysis.

OBJECTIVES: To compare the cost of open transvesical prostatectomy (OP) with that of holmium laser enucleation (HoLEP) in the treatment of bladder outlet obstruction (BOO) attributed to benign prostatic hyperplasia. METHODS: From February to May 2004, 63 consecutive patients with symptomatic benign prostatic hyperplasia in a large prostate (70 to 220 g) and documented BOO were randomized to surgical treatment with OP (29 in group 1) or HoLEP (34 in group 2). All costs associated with the procedures during the hospital stay were recorded prospectively, and a cost-effectiveness analysis of the critical perioperative (ie, intraoperative and postoperative to hospital discharge) data was performed. RESULTS: The cost analysis showed a mean perioperative cost of 2868.9 euros (3556.3 dollars) for group 1 and 2356.5 euros (2919.4 dollars) for group 2. A direct comparison analysis showed that the most significant cost factors were the operative time (average 16.1% and 25.1% to the cost of OP and HoLEP, respectively), operating room surgical setup/disposables, including laser fiber and resectoscope loop in group 2 (average 13.3% and 29.3% to the cost of OP and HoLEP, respectively), and length of postoperative hospital stay (average 53.3% and 32.0% to the cost of OP and HoLEP, respectively). Overall, the hospitalization cost of HoLEP was 9.6% less than that for OP. CONCLUSIONS: Our data have demonstrated that HoLEP is associated with a significant hospital net cost savings compared with OP in patients undergoing surgery for symptomatic benign prostatic hyperplasia in large glands.

Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up.

OBJECTIVE: Prospectively evaluate perioperative outcomes and 2-yr follow-up after holmium laser enucleation (HoLEP) and standard open prostatectomy (OP) for treating benign prostatic hyperplasia-related obstructed voiding symptoms, with prostates >70 g. METHODS: From March 2003 to December 2004, 80 consecutive patients were randomised for surgical treatment with HoLEP (n=41) or standard OP (n=39). All patients were preoperatively assessed with International Prostate Symptom Score and International Index of Erectile Function questionnaires and complete urodynamic evaluation. Intraoperative and perioperative parameters such as blood loss, catheter removal, and hospital stays were assessed. Early and late complications were recorded. Patients were evaluated at 1-, 3-, 12-, and 24-mo follow-ups with the same tests. RESULTS: Operating room time was significantly shorter for the OP group (72.09+/-21.22 min vs. 58.31+/-11.95 min, p<0.0001); catheter removal (1.5+/-1.07 d and 4.1+/-0.5 d, p<0.001) and hospital stay (2.7+/-1.1 d vs. 5.4+/-1.05 d, p<0.001) were shorter in the HoLEP group. Blood loss was less and blood transfusions fewer in the HoLEP group (p<0.001). In both groups urodynamic and uroflowmetry findings improved from baseline, were still evident at the 24-mo follow-up, and were comparable between the two groups. Late complications were also comparable. CONCLUSIONS: HoLEP is a feasible technique for treating large prostates. Functional results are similar to OP at the 2-yr follow-up. Reduced catheterisation, hospital stay, and blood loss make HoLEP an attractive option for the treatment of large prostates.

Dorsal onlay graft urethroplasty using penile skin or buccal mucosa for repair of bulbar urethral stricture: results of a prospective single center study.

OBJECTIVE: To compare the outcomes of dorsal onlay graft urethroplasty using penile skin (PS) or buccal mucosa (BM) free grafts in the repair of adult bulbourethral strictures. METHODS: From January 1998 to March 2003, 30 patients with bulbar urethral strictures underwent urethral reconstruction with PS (17) or with BM free graft (13). Follow-up was done at 6, 12 and 18 months postoperatively, and every year subsequently. Success was defined as normalization of IPSS and a stable Q(max) value >20 ml/s. Any further instrumentation for stricture recurrence was considered a failure. RESULTS: Mean follow-up was 51 months (20-74). The overall success rate was 80% (85% in the BM and 76% in the PS group). Improvement of uroflowmetry, IPSS and QoL did not show a significant difference between the two groups. A significant improvement of the orgasmic function domain of the IIEF was found in patients treated with a PS graft. Post-operative complications were lip hypoesthesia (30%), retraction of the ventral skin of the penis (7%), post-voiding dribbling (8% with BM graft, and 7%, with PS graft). Six patients, 2 with BM (15%) and 4 with PS graft patch (24%) required further treatment due to stricture recurrence. CONCLUSION: Results of PS or BM graft are comparable at 18 month follow-up, although orgasmic function is significantly improved in patients receiving a PS graft. Nevertheless, with extended follow-up, the use of PS seems to be associated with a higher failure rate.

Overall clinical outcomes after nerve and seminal sparing radical cystectomy for the treatment of organ confined bladder cancer.

PURPOSE: We assessed postoperative clinical outcomes such as day and nighttime urinary continence and overall sexual function in patients who underwent nerve and seminal sparing cystectomy with ileocapsuloplasty compared with patients after standard cystoprostatectomy with similar orthotopic urinary reservoir. MATERIALS AND METHODS: A total of 27 patients (mean age 52 years, range 36 to 61) with superficial high risk or muscular invasive T2 bladder cancer underwent radical nerve and seminal sparing cystectomy with ileocapsule anastomosis. Postoperative clinical outcomes such as urinary continence, voiding patterns and urodynamic parameters were evaluated at 3, 6 and 12 months, while overall sexual function was determined at baseline and at 6 and 12-month followup. RESULTS: Nerve and seminal sparing cystectomy provides better outcomes in terms of urinary and urodynamic parameters compared to standard cystoprostatectomy. Furthermore, fully normal postoperative erectile function and satisfactory overall sexual quality of life were documented at early and delayed followup in all patients. A retrograde ejaculation with reliable sperm retrieval from urine was also documented. CONCLUSIONS: Although these findings need to be confirmed in a larger patient population, when respecting rigorous patient selection criteria and careful postoperative surveillance, nerve and seminal sparing cystectomy seems to offer satisfactory clinical and functional outcomes. From an oncological point of view, long-term followup is of paramount importance to confirm whether this surgical procedure can be proposed as a valid choice of treatment for young, fully potent and socially active patients with organ confined bladder cancer.