Transperineal biopsy under ultrasound guidance for prostate cancer detection as an initial and as a repeat biopsy strategy

OBJECTIVE: To present the authors' experience on transperineal prostate sector biopsy (TPSB) in detecting prostate cancer, in identifying both low Gleason prostate cancers as well as clinically significant prostate cancer (Gleason 7 and higher), and in determining anatomical distributions of prostate cancer in both initial and repeat biopsy settings.METHODS: All patients from June 2014 to September 2016 who underwent TPSB, as initial biopsy or repeat biopsy after previous negative transrectal ultrasound-guided biopsy (TRUSPNB) were included. Data for each patient were collected prospectively and subjected to statistical analysis. T test was used for continuous variables while Chi square test or Fisher exact test was used for categorical variables. Multiple logistic regression models were used to identify factors predictive of a positive result.RESULTS: A total 130 patients were included in the study, 73 had TPSB as initial biopsy and 57 as repeat biopsy after previous negative TRUSPNB. The mean patient age of the Initial Biopsy Group (IBG) was 66 years while the mean age for the Repeat Biopsy Group (RBG) was 68 years. The IBG had a lower mean serum PSA level (9.07 ng/mL for IBG and 9.59ng/mL for RBG) and smaller prostate volumes (42.9 mL for the IBG and 44.3mL for the RBG). Prostate cancer was detected in 65.8% (48/73) of the IBG and 40.4% (23/57) of RBG, of which 77.1% (37/48) and 73.9% (17/23) respectively, were clinically significant, defined as a Gleason score of ?7. Of the cancers detected in IBG, 29.2% (14/48) exclusively involved the anterior sector (based on the Ginsburg Study Group's biopsy map), while 30.4% (7/23) were conned exclusively within the anterior sector for the RBG. Increasing PSA level and lower prostate volumes were predictive of cancer detection in RBG, while only increasing PSA level was predictive of a positive result in IBG.CONCLUSION: Transperineal prostate sector biopsy demonstrated a high prostate cancer detection rate for both the initial and repeat biopsy settings. Likewise it provides for excellent sampling of the anterior region of the prostate, as it affords a more accurate sampling of the prostate gland based on a preplanned map and template to sample areas of interests. Similarly, it detects a high proportion of patients with clinically significant prostate cancer. This technique should therefore be highly considered as a first line option for all patients in whom a prostate biopsy is warranted.

A comparative study on the diagnostic efficacy and safety of ultrasound-guided transperineal and transrectal prostate needle biopsy

OBJECTIVE: To compare the diagnostic efficacy between the transperineal and the transrectal prostate needly biopsy as the initial biopsy strategy for detection of prostate cancer.METHODS: A total of 179 patients with PSA of 2.5-20 ng/mL who underwent initial prostate needle biopsy were included. One hundred eight (108) patients underwent transrectal prostate needle biopsy (TRUS-BX) from March to December 2014, while 71 patients underwent transperineal prostate needle biopsy (TP-BX) from January 2015- August 2016. Descriptive statistics including mean, median and percentage were used for the patient demographics. Student's t-test was used to compare continuous variables between the two groups. X2 or Fisher's exact probability tests were used for categorical variables.RESULTS: The mean age of the patients who underwent the TP-BX and TRUS-BX were 66.10 years and 62 years respectively (p=0.0003). The mean prostate volumes were 44.10 mL and 42.39 mL (p=0.5405), while the mean PSA were 9.51 ng/mL and 9.21 ng/mL (p=0.6096) for the TP-BX and TRUS-BX,respectively. The TP-BX provided a greater overall cancer detection rate of 63.38% (45/71) compared to 35.19% (38/108) obtained from the TRUS-BX (pCONCLUSION: The transperineal prostate needle biopsy should be considered as the initial biopsy strategy for the detection of prostate cancer. The manifested advantages are the following: a) The overall cancer detection rate is significantly higher, b) The detection rate of clinically significant cancer is significantly greater, c) It provides a far more superior detection of exclusive anterior zone cancers which are often under detected or undetected with the current standard TRUS-BX and d) Complications are comparable, if not fewer than the current standard TRUS-BX.

A comparative study on the operative outcomes of a novel technique of continuous versus interrupted vesicourethral anastomosis in open radical retropubic prostatectomy

OBJECTIVE: Vesicourethral anastomosis (VUA) is the most technically challenging part in open radical retropubic prostatectomy (ORRP). Traditionally, it is accomplished using interrupted anastomotic sutures. The objective of this study is to describe our surgical technique of continuous VUA and compare its outcomes with that of interrupted VUA as performed by a single surgeon. MATERIALS AND METHODS: A total of 235 patients with clinically localized prostate cancer who underwent ORRP since February 2000 to June 2013 were included. They were divided into Group 1 (n=121) using interrupted VUA and Group 2 (n=114) using our technique of continuous VUA. Primary outcome measures to be evaluated include several operative parameters with respect to operative time, blood loss, anastomotic integrity, hospital stay, continence, potency and occurrence of VUA stenosis. Analysis was done using Welch's t-test and Fisher's exact test. All the statistical tests were performed using SPSS 20.0. P-values less than 0.05 indicate statistically significant difference. RESULTS: Patients who underwent continuous VUA (Group 2) had significantly less operative time (210.05 ± 1.91 vs 251.37 ± 2.74 mins, P CONCLUSIONS: Our technique of continuous VUA for ORRP provides better outcome compared to standard interrupted VUA.

Survival outcomes among men with clinically localized prostate cancer treated with radical prostatectomy, brachytherapy, cryosurgical ablation and intensity-modulated radiotherapy: A single surgeon local experience

OBJECTIVE: Radical prostatectomy (RP), brachytherapy, cryosurgical ablation and intensity-modulated radiotherapy (IMRT) are accepted treatment options for localized prostate cancer. The objectives of this study were to determine the overall survival (OS), disease specific survival (DSS) and biochemical no evidence of disease (BNED) rates of the patients who underwent these different treatment modalities. MATERIALS AND METHODS: A total of 485 patients with localized prostate cancer treated with RP (n=235), brachytherapy (n=202), cryosurgical ablation (n=33), and IMRT (n=15) were identified from the database of a single urological practice. Analysis of variance (ANOVA) was used to compare means of patients. Chi-square test was used to compare percentages. Kaplan-Meier survival analysis was used to determine if the outcome parameters significantly differed according to the methods. P-values less than 0.05 indicate significant difference. All the statistical tests were performed using SPSS 20.0. RESULTS: The OS rate after RP, brachytherapy, cryosurgical ablation and IMRT were 97.9%, 89.1%, 93.9% and 93.3%, respectively. The DSS rate was 99.6%, 98.0% and 97.0%. respectively. No mortality from prostatic cause was reported from IMRT. The BNED rate was 90.6%, 88.1%, 78.8% and 93.3%, respectively. CONCLUSION: The overall and disease specific survival were comparable among all treatment modalities. Although radical prostatectomy and IMRT showed an overall better BNED outcomes, this advantage disappeared when the patients were analyzed according to their respective risk stratification into low, moderate and high risk group.

Long term outcomes of permanent I-125 prostate seed implant for early prostate cancer

OBJECTIVE: Since its introduction in the Philippines in 2001, low dose rate brachytherapy (permanent I-125 prostate seed implant) has become one of the widely utilized modality for the treatment of localized prostate cancer. This study aimed to evaluate the long-term clinical outcomes of low dose rate prostate brachytherapy (Permanent I-125 Prostate Seed Implant) in terms of overall survival (OS), disease specific survival (DSS), biochemical no evidence of disease (BNED), complications and mortality. MATERIALS AND METHODS: Two hundred and two consecutive patients who underwent permanent I-125 prostate seed implant from April 2002 to December 2012 were included in this study. The details of all patients were derived from the database of a single urologist. The median follow up is 6.3 years. Kaplan-Meier curves were used to evaluate overall survival, prostate cancer specific survival and biochemical no evidence of disease (defined by the ASTRO criteria) across all disease risks. Treatment-related complications and causes of mortality were also reviewed. RESULTS: The 11-year overall survival and disease-specific survival rates were 89.1% and 98%, respectively. The biochemical no evidence of disease was 82.7%. Log rank testing showed that survival in terms of OS, DSS, and BNED did not differ significantly regardless of risk stratification into low, moderate and high risk groups. The treatment-related morbidity rate for this series was 5.4%. CONCLUSION: Brachytherapy is an effective treatment for localized prostate cancer with favorable long term survival results, durable biochemical outcomes, and minimal toxicity.

A comparison between voiding patterns of healthy infants and those with recurrent UTI

OBJECTIVE: The purpose of this study was to compare voiding patterns of healthy infants and those with recurrent UTI aged 1-24 months.METHODS: This was an analytical, cross sectional study of healthy infants and those with recurrent UTI, aged 1-24 months from March 1999 to March 2000 seen at University of Santo Tomas Hospital. The study included 100 subjects; Group I (50 subjects) healthy infants (neurologically intact with other anomalies ruled out by ultrasound and voiding cystourethrogram) Group 2 (50 subjects) are those with recurrent UTI. During the 24-hour period, all micturitions were recorded in terms of voiding frequency, volume and character of voiding. The observation was completed with three determination of residual urine volume using ultrasound by a single sonologist who did not know the diagnosis of each case. Voiding patterns in terms of mean voiding frequency, mean volume per voiding, mean functional bladder capacity and character of voiding were determined. Mean residual urine volume was also determined in milliliters. The two groups were compared using T test with a p value of 0.05 percent at 95 percent confidence interval.RESULTS: The mean voiding frequency was 17.03 (SD +/- 7.5) in-group 1 and 13.5 (SD +/- 4.9) in-group 2 (p value of 0.009) The mean volume per voiding was 33.88 (SD +/- 15.2) on group 1 and 40.12 (SD +/- 37.4) in Group 2 (p value of 0.27). The mean bladder capacity was 44.02 (SD +/- 29.5) in group 1 and 66.48 (SD +/- 29.4) in group 2 (p value 0.00). In group 1 subjects, twenty eight percent showed interrupted voiding pattern compared to none in group 2 (p value 0.00). The mean residual urine volume for group 1 was 7.97 (SD +/- 7.5) and 6.06 (SD +/- 6.6) in group 2 (p value 0.183).CONCLUSION: The voiding patterns of pediatric patients with recurrent UTI were significantly characterized by increased frequency, decreased functional bladder capacity, and interrupted voiding. Mean volume per voiding was also decreased in those with recurrent UTI but not to a significant degree. Determination of residual urine in those with recurrent UTI was not significantly different from healthy infants.

Technical refinements of transrectal ultrasound-guided prostate biopsy in prostate cancer detection

Rationale: In the Philippine setting, prostate cancer detection using sextant biopsy techniques yielded result ranging from 6-10 percent. However, with the introduction of the 12 core systematic biopsy technique, the cancer detection increased to 23 percent. The yield is still inferior compared to foreign counterpart and a deeper reassessment of the biopsy technique may prove otherwiseObjective: This study aims to evaluate cancer detection using a technical refinement wherein an ultrasound machine is used to visualize the prostate gland both in sagittal and longitudinal views, directing the biopsies more laterally to better sample regions of the peripheral zone using the marker lineMethods: This is a prospective cohort study of 68 consecutive males who underwent prostate biopsy from two tertiary hospitals performed by one consultant from January to September 2004. The indications for prostate biopsy included an elevation of serum PSA and/or an abnormal digital rectal examination. However, due to higher likelihood of prostate cancer in men with higher PSA, patients with PSA above 20 ng/ml were excluded from this study. The ultrasound machine used in Group A was ACUSON while that in group B used Bruel Kjaer 5001. All patients underwent a systematic 12 core biopsy techniqueResults: A total of 68 male patients with a mean age of 66.11 +/- 8.09 years, who underwent transrectal ultrasound guided prostate biopsy using the twelve core protocol from January to September 2004 were included. Twenty-eight (28) patients were included in group A and 40 were in group B. The pre-biopsy PSA level taken showed a mean of 9.55 +/- 3.03. The mean prostate gland volume on transrectal ultrasound was 39.67 +/- 13.6 and 39.67 +/- 16.9 for group A and B, respectively. The overall cancer detection rate from the total study population was 41.3 percent. Detection rate of the two populations were compared using the Wilcoxon Signed Rank Test and the Mc Nemars Test. The detection rate for group A was 21 percent while the detection rate for group B using the technical modification was 50 percent. There was a significant difference in cancer detection between the two populations at z= 2.53, p=0.01 using Wilcoxon Signed Rank Test and at p=0.02 in Mc Nemars test. Reliability analysis was also done to determine differences in the detection rates of the tests done in the two different institutions. Friedmans chi square, x2 was 14.8 at p=0.002, which means that the detection rates between the two institution was significantly differentConclusion: The prostate biopsy technique of using biplanar transrectal probe that allows confirmation of the needle tract in the transverse view before doing the biopsy in the sagittal view of the prostate increased the yield of prostate cancer detection to 50 percent. The conventional 12 core biopsy technique still maintained a 21 percent detection, which is not different from previous reports from the same institution. (Author)

Retroperitoneal laparoscopic adrenalectomy: A documentation of the first case in the country

The initial experience in laparoscopic adrenalectomy has been performed transperitoneally. To further minimize the invasiveness, the concept of retroperitoneal laparoscopy was developed and is rapidly gaining grounds as the standard of care. Locally, surgeons have been reluctant in adopting this remarkable alternative due to lack of facilities, experience and support. Thus, only 4 cases of laparoscopic adrenalectomies, all via the transperitoneal approach, had been performed for the past 4 years. Considering the limited experience, inadequate facilities and instruments, still, it was successfully performed with some procedural innovations and technical modifications. It follows the principles of minimally invasive surgery that can avoid some of the physiologic and technical complications of transperitoneal laparoscopic adrenalectomy in the country. It proves the possibility of the procedure in the local setting. As an innovative addition to urological practice, retroperitoneal laparoscopic adrenalectomy can therefore serve as an alternative treatment procedure for benign adrenal pathologies. (Author)

Tubularized tunica vaginalis graft for male urethral reconstruction

Graft substances such as skin, bladder and buccal mucosa have been used for urethral replacement when local epithelial tissue is not available. However, these subtances have been associated with meatal prolapse, stricture and fistula formation. We tried tunica vaginalis as a urethral graft in rabbitsA graft of tunica vaginalis was placed in the excised portion of the urethra in five experimental rabbits. After 6 weeks retrograde urethrograms revealed no strictures and a fistula formation in one rabbit. The histopathologic examination revealed that the tunica vaginalis was covered by the transitional epithelium of the urethra. The tunica vaginalis could be used as a urethral graft in animals with a fistula formation as a complication. (Author)