[Value of PCA3 urinary test for prostate biopsy decision: the Lyon-Sud University Hospital experience]. / Intérêt du test urinaire PCA3 dans la décision de biopsie prostatique : l'expérience du Centre hospitalier Lyon-Sud.

The poor specificity of diagnostic strategy for prostate cancer (digital rectal examination and seric PSA) induces both a great number of useless prostate biopsies and diagnosis of non evolutive cancers. A urinary test (Progensa PCA3(®), Gen-Probe) measuring the expression of PCA3, a prostate cancer-specific gene, has recently be proposed to indicate re-biopsy. The aim of this prospective study was to evaluate diagnostic value of urinary PCA3 test for prostate cancer. In the urines of 245 patients submitted to prostate biopsy, expression of the PCA3 gene was measured and reported to that of PSA to calculate PCA3 score using a method amplifying and detecting RNA. Patients with informative samples (98%) were classified depending of the presence (n = 126) or absence (n = 114) of cancer tissue on biopsies. The median PCA3 score was significantly higher in the group with positive biopsies (p < 0.0001). Area under ROC curve was 0.70 for PCA3 as compared to that of PSA (0.53) and free/total PSA ratio (0.65). At the best threshold of 38, PCA3 test had a 59%-sensitivity and a 72%-specificity, as compared to 66% and 32% for total PSA (threshold 4 ng/mL) and 81% and 28% for free/total PSA ratio (threshold 25%). These performances were maintained in patients with seric PSA within the grey zone (4-10 ng/mL) and those with previous prostate biopsies. This study confirms the clinical value of PCA3 urinary test in helping decision for biopsies in patients with suspected prostate cancer.

[Value of urinary markers in the diagnosis and follow-up of urothelial bladder tumours]. / Intérêt des marqueurs urinaires dans le diagnostic et le suivi des tumeurs urothéliales de vessie.

Urothelial bladder tumours require regular surveillance: cystoscopy associated with urine cytology are reference examinations. Several new markers currently under evaluation or already validated have recently been proposed to replace cytology and potentially reduce or even replace unnecessary cystoscopies. The biological fluid studied for all of these markers is the same as that of urine cytology, i.e. urine. The authors review the results of recent studies on these new urinary markers. The results of these markers demonstrate a better global sensitivity than urine cytology, but often a lower specificity. In the majority of cases, these tests are performed during patient follow-up (NMP22, BTA, CYFRA 21-l., etc.), but do not replace cystoscopy, due to a large number of false-positives. Other techniques, such as FISH, uCyt+ or microsatellites appear to be more promising, especially for the diagnosis of low-grade tumours. The best solution in practice may consist of a combination of several markers to further improve sensitivity and to decrease the false-positive rate responsible for unnecessary cystoscopies.

[REMEEX: A possible treatment option in selected cases of sphincter incompetence]. / REMEEX: une option thérapeutique envisageable dans des cas sélectionnés d'insuffisance sphinctérienne.

OBJECTIVE: To evaluate the functional results and morbidity of adjustable tension suburethral tape (REMEEX) in the treatment of urinary incontinence due to severe sphincter incompetence (MUCP < 40 cm H2O) in patients presenting a contraindication to artificial sphincter operated between December 2001 and May 2004. Twelve patients (66.7%) had already undergone incontinence surgery. Ten patients (55.5%) had mixed urinary incontinence. The efficacy of the tape was considered to be good when incontinence resolved completely, partial when incontinence was decreased by > 50% and/or PVR > 100 ml. All other cases were considered to be failures. In April 2005, after a mean follow-up of 26.3 months, retrospective evaluation of the functional results was performed by means of a pad-test and a questionnaire comprising an MHU (urinary disability) score and a Ditrovie score. Complications after each intercurrent event were recorded. RESULTS: The initial efficacy of the tape was considered to be good in 13 patients (72.2%) and partial in 4 patients (22.2%) with only one initial failure. Eight patients (44.4%) required secondary adjustment after a mean interval of 5.2 months, with a failure rate of 62.5%. In April 2005, 10 patients (55.5%) had a good result, 2 patients (11.1%) required self-catheterization (partial efficacy) and 6 patients (33.4%) were considered to be failures. In terms of morbidity, we observed 2 bladder injuries (11.1%), 6 superinfections of the device (33.3%), 2 (11.1%) of which required removal of the material. Fifteen patients (83.3%) answered the questionnaire: 6 patients (40%) had an MHU score greater than 3. The mean Ditrovie score was 2.1. 9 patients (60%) had a score less than 2 and 4 patients (26.6%) had a score greater than 3. CONCLUSION: The results of this series, in patients in whom artificial sphincter was contraindicated, are satisfactory at the price of acceptable morbidity. Before defining the place of this device in the range of treatment options for sphincter incompetence, our results must be confirmed by a longer series.

[Complications and functional results of Hautmann ileal bladder in a series of 87 patients]. / Complications et résultats fonctionnels de la vessie iléale de Hautmann: a propos de 87 patients.

OBJECTIVES: To retrospectively evaluate the complications, urinary reservoir function and quality of life of patients with Hautmann ileal bladder after cystectomy for bladder urothelial carcinoma. METHODS: From 1994 to 2004, 87 patients with a mean age of 61.1 years underwent total cystoprostatectomy (n = 85 men) or radical cystectomy (n = 2 women) with Hautmann replacement enterocystoplasty. The mean follow-up was 40.7 months. Continence, quality of voiding, and quality of life were evaluated by self-administered questionnaires (continence questionnaire, DITROVIE score, I-PSS score). RESULTS: The early complication rate was 30.1%, including 6.9% related to the ileal bladder. The late complication rate was 33.6%, including 20.9% related to the ileal bladder. Four patients died during the perioperative period, 14 patients (17%) died from progression of their cancer and 7 patients (8%) died from an independent cause. One patient was lost to follow-up. Questionnaires were sent to 56 patients and 52 replies were received: 96.2% of patients were continent during the day, 53.8% were continent at night. 4.9% of patients performed self-catheterization for chronic urine retention, 90.4% of patients were satisfied with their replacement bladder and only 5.8% of patients had an altered quality of life. CONCLUSION: Despite a considerable morbidity rate and a significant nocturnal incontinence rate, the orthotopic Hautmann W-shaped ileal bladder does not appear to alter the patients' quality of life.

Prostate cancer detection rate in patients with repeated extended 21-sample needle biopsy.

BACKGROUND: Prevalence of prostate cancer (PCa) after a negative first extended prostate needle biopsy protocol is unknown. OBJECTIVE: To evaluate the prevalence of significant PCa in patients who have had a negative first extended prostate biopsy protocol. DESIGN, SETTING, AND PARTICIPANTS: Between March 2001 and May 2007, 2500 consecutive patients underwent an extended protocol of 21 biopsies. Of 953 patients who had a negative first extended prostate biopsy procedure, 231 patients underwent a second or more set of 21-core biopsies. Indications for repeated biopsies were persistently elevated prostate-specific antigen (PSA), PSA increase during the follow-up, or prior prostatic intraepithelial neoplasia (PIN), or atypical small acinar proliferation (ASAP). INTERVENTION: All participants underwent at least two extended prostate needle biopsy protocols. MEASUREMENTS: Clinical and pathologic factors (age, PSA, PSA doubling time, PIN, ASAP, digital rectal exam [DRE]) were analyzed for their ability to predict positive biopsy, and tumour parameters were assessed in patients undergoing radical prostatectomy. RESULTS AND LIMITATIONS: Second, third, and fourth extended 21-sample biopsy procedures yielded a diagnosis of PCa in 18%, 17%, and 14% of patients respectively. Patients with prior PIN had 16% risk of prostate cancer; patients with ASAP had a 42% risk. The mean number of positive cores was 2.19. Prostate volume and PSA density were statistically significant predictors of positive biopsy (p<0.05). For the 43 patients who underwent radical prostatectomy, pathologic findings revealed mean Gleason score of 6.7 (6-8), pT2a-c in 72%, pT3a in16%, and pT4 in 7%. Mean cancer volume was 1.15 cc and 85.2% of tumours were clinically significant (tumour volume > 0.5 cc, Gleason > or = 7 and/or pT3). CONCLUSIONS: Negative first extended biopsies should not reassure a patient of not having PCa. However, prostate cancers detected after two or more sets of extended procedures, appear to be localized (intracapsular disease) and well-differentiated prostate cancers, although they are still clinically significant.