Contemporary management of small renal tumors.

The incidence of kidney cancer in the United States is rising because the increased use of cross-sectional imaging is resulting in more tumors being detected and because the population is aging. In addition, a stage migration in kidney cancer has been observed—again because of improved detection—with an increase in stage T1 tumors and a concomitant decrease in the number of stage T2 to T4 tumors. Recent studies have shown that up to 80% of small renal tumors (SRTs) either have an indolent course or are histologically benign. These fndings raise the question of what the optimal management of SRTs should be. Radical nephrectomy, the traditional, most aggressive, and still most frequently used extirpative surgery, has been shown to increase the risk of chronic kidney disease. Therefore, during the past 2 decades there has been a shift toward nephron-sparing surgery in carefully selected patients as such procedures have demonstrated equivalent oncologic outcomes with a decrease in long-term renal-induced morbidities. More recently, thermal ablative techniques have evolved as a reliable minimally invasive option for SRTs that can provide adequate oncologic control with minimal morbidity. Finally, in patients with limited life expectancies, active surveillance may be a reasonable approach given the slow median growth rate of SRTs. In evaluating patients with SRTs, percutaneous renal biopsies are being used safely and with increasing accuracy, providing valuable histologic information that can be used to guide the management of SRTs. This article will explore the approaches to managing and treating this growing cohort of patients with SRTs, which are usually incidentally identifed.

Iatrogenic nonendoscopic bladder injuries over 24 years: 127 cases at a single institution.

OBJECTIVE: To analyze the etiology, diagnosis, and long-term outcomes of iatrogenic nonendoscopic bladder injuries over a 24-year period. METHODS: All iatrogenic bladder injuries were entered prospectively into our database from 1990 to 2014. Information gathered included causative procedure, injury characteristics, management, and outcome. RESULTS: A total of 127 patients with nonendoscopic iatrogenic bladder injuries were included (111 women [87%], 16 men [13%]; mean age 51 years [range, 23-84]). Risk factors were identified in 92 patients (79%) including prior surgery, inflammation, and extensive tumor. Obstetric-gynecologic surgery accounted for most injuries (65%), with hysterectomy the most common procedure, followed by cesarean section. General surgery and nonendoscopic urologic injuries accounted for 22% and 13% respectively. Most injuries occurred during open surgery (77%) compared with vaginal (12%) and laparoscopic surgeries (11%). Laparoscopic surgery was associated with a delay in diagnosis, P=.002. Bladder injuries with concomitant ureteral injuries were more likely to have long-term complications, P=.001. CONCLUSION: In analyzing iatrogenic bladder injuries at our institution over 24 years, we observed that hysterectomy and cesarean sections were the 2 most common causative procedures. A delay in diagnosis was more likely to occur during laparoscopic surgery. Complications occurred more commonly with a concomitant ureteral injury.

Single-surgeon experience of 87 buccal mucosal graft harvests.

UNLABELLED: Although buccal mucosa has been the preferred graft material for use in the reconstruction of anterior urethral strictures for approximately 20 years, the plastic surgery literature is lacking in studies describing and evaluating this technique. The authors sought to report their experience with the technique of buccal mucosa graft harvest for use in urethral reconstruction. The authors identified 87 consecutive patients who underwent buccal mucosal graft harvesting during a 15-year period from 1995 to 2010. All donor sites were closed primarily. Preoperatively, a specialty-specific evaluation was performed by plastic surgeons and urologists. Postoperative donor-site morbidity was followed clinically. Eighty-seven patients underwent buccal harvesting. A single buccal graft was harvested in 75 patients (86.2 percent) and bilateral grafts were harvested in 12 patients (13.8 percent). The median patient age of the patients was 42 years (range, 16 to 78 years). There were no major intraoperative or postoperative complications. Minor complications included mild discomfort, numbness, cheek swelling, and restriction of oral movement, all of which resolved by the 3-month postoperative visit. The ability to eat and drink postoperatively was diminished during only the first 24 to 48 hours in all patients. Our series provides a 1-year follow-up in a substantial cohort looking at clinical outcomes after buccal harvesting. These results confirm the safety and efficacy of buccal mucosal harvesting to provide an effective and cosmetically superior option for urethral reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Adequacy of low dose computed tomography in patients presenting with acute urinary colic.

BACKGROUND AND PURPOSE: Noncontrast abdominal/pelvic CT is the current imaging standard for patients who present with acute urinary colic. Conventional CT, however, exposes the patient to significant amounts of ionizing radiation, which is cumulative when additional CTs are used to monitor stone migration, outcomes, etc. We sought to maintain diagnostic adequacy while decreasing our patients' radiation exposure from CT by using a reduced tube current, an abbreviated scanning area, and the use of coronal reformatted images. PATIENTS AND METHODS: Between March 3, 2011 and October 31, 2011, 101 consecutive adult patients with suspected urinary colic were evaluated with a "low" dose CT. If the suspected calculus(i) was not seen, the patient underwent immediate conventional CT imaging customized to their body habitus. Radiation exposure for each patient was calculated using an established formula of dose length product and scan length. The effective total radiation dose was measured in millisieverts (mSv). RESULTS: Overall, 84 patients had an upper tract calculus(i) consistent with the clinical suspicion. Of these, 76 (90%) were adequately imaged with low dose and 8 (10%) with conventional noncontrast CTs. The mean effective radiation dose in the 76 low dose stone-positive CTs was 2.14 mSV (median 2.10 mSv). This was almost seven-fold lower than the mean conventional stone-positive CT dose of 14.5 mSv (median 13.1 mSv). CONCLUSIONS: Low dose noncontrast CT provided adequate imaging to guide optimal urologic management in the majority of our patients. This modality offered a significantly lower ionizing radiation dose and should be considered in patients who present with acute urinary colic.

Perioperative patient radiation exposure in the endoscopic removal of upper urinary tract calculi.

BACKGROUND AND PURPOSE: The efficacy of computed tomography (CT) in detailing upper urinary tract calculi is well established. There is no established acceptable annual recommended limit for medical exposure, yet the global accepted upper limit for occupational radiation exposure is <50 millisieverts (mSv) in any one year. We sought to appreciate the CT and fluoroscopic radiation exposure to our patients undergoing endoscopic removal of upper tract calculi during the periprocedure period. PATIENTS AND METHODS: All patients undergoing upper urinary endoscopic stone removal between 2005 and 2009 were identified. To calculate the cumulative radiation exposure, we included all ionizing radiation imaging performed during a periprocedure period, which we defined as ≤90 days pre- and post-therapeutic procedure. RESULTS: A total of 233 upper urinary tract therapeutic patient stone procedures were identified; 127 patients underwent ureteroscopy (URS) and 106 patients underwent percutaneous nephrolithotomy (PCNL). A mean 1.58 CTs were performed per patient. Ninety (38.6%) patients underwent ≥2 CTs in the periprocedure period, with an average number in this group of 2.49 CT/patient, resulting in approximately 49.8 mSv of CT radiation exposure. Patients who were undergoing URS were significantly more likely to have multiple CTs (P=0.003) than those undergoing PCNL. Median fluoroscopic procedure exposures were 43.3 mGy for patients who were undergoing PCNL and 27.6 mGy for those patients undergoing URS. CONCLUSIONS: CT radiation exposure in the periprocedure period for patients who were undergoing endoscopic upper tract stone removal is considerable. Added to this is the procedure-related fluoroscopic radiation exposure. Urologic surgeons should be aware of the cumulative amount of ionizing radiation received by their patients from multiple sources.

A randomized prospective trial of primary versus AlloDerm closure of buccal mucosal graft harvest site for substitution urethroplasty.

OBJECTIVES: To present a prospective, randomized trial comparing primary and AlloDerm closure of the oral harvest site. The use of buccal mucosa grafts for substitution urethroplasty is an established and durable technique. The optimal management of the buccal mucosa grafts harvest site for the intraoral defect has yet to be determined. METHODS: Between February 2003 and September 2006, a total of 20 men undergoing buccal mucosal urethroplasty were randomly assigned to either primary (n = 10) or AlloDerm closure (n = 10) of the oral harvest site. All patients were clinically examined postoperatively and each completed a 10-point analog pain score and descriptive questionnaire postoperatively, at 3 weeks, and at 3, 6, and 12 months. RESULTS: A 100% of patients completed the study at 12 months follow-up. Oral pain dissipated acutely after 3 weeks. No significant differences in either neurosensory or mouth tightness symptoms were noted, except increased incidence of cheek swelling at 3 weeks in the AlloDerm group. CONCLUSIONS: AlloDerm proved to be an effective means of closing the harvest site, but offered no significant advantages when compared with primary closure. AlloDerm closure was associated with increased morbidity in mouth tightness symptoms, cheek swelling, and discomfort while chewing food; only increased incidence of cheek swelling at 3 weeks was found to be significant. Despite its excellent molecular properties and nonimmunogenic nature, the role of AlloDerm graft use in closing the buccal mucosal harvest site appears to be an unnecessary step. Primary closure was extremely well tolerated in both short- and long-term follow-up, with minimal sequelae at 12 months.

Xanthogranulomatous orchitis in a patient with a history of instrumentation and bacillus Calmette-Guérin therapy.

Xanthogranulomatous orchitis (XGO) is a rare histological finding that is generally diagnosed at orchiectomy. To date, fewer than 10 reports of XGO exist in the literature. The exact pathogenesis of XGO is unknown and patients may present with a rapid onset of symptoms or a longer, more indolent course. We report a patient who presented with symptoms of epididymoorchitis, leukocytosis, and fever after an instillation of bacillus Calmette-Guérin therapy for bladder cancer.

The poppy seed test for colovesical fistula: big bang, little bucks!

PURPOSE: Diagnosis of a colovesical fistula is often challenging, and usually involves numerous invasive and expensive tests and procedures. The poppy seed test stands out as an exception to this rule. We evaluated the accuracy and cost-effectiveness of various established diagnostic tests used to evaluate a suspected colovesical fistula. MATERIALS AND METHODS: We identified 20 prospectively entered patients with surgically confirmed colovesical fistulas between 2000 and 2006. Each patient was evaluated preoperatively with a (51)chromium nuclear study, computerized tomography of the abdomen and pelvis with oral and intravenous contrast medium, and the poppy seed test. Costs were calculated using institutional charges, 2006 Medicare limiting approved charges and the market price, respectively. The z test was used to compare the proportion of patients who tested positive for a fistula with each of these modalities. RESULTS: The chromium study was positive in 16 of 20 patients (80%) at a cost of $490.83 per study. Computerized tomography was positive in 14 of 20 patients (70%) at a cost of $652.92 per study. The poppy seed test was positive in 20 of 20 patients (100%) at a cost of $5.37 per study. The difference in the proportion of patients who tested positive for a fistula on computerized tomography and the poppy seed test was statistically significant (p = 0.03). There was no difference between the chromium group and the computerized tomography or poppy seed group (p = 0.72 and 0.12, respectively). CONCLUSIONS: The poppy seed test is an accurate, convenient and inexpensive diagnostic test. It is an ideal initial consideration for evaluating a suspected colovesical fistula.

Scrotal reconstruction using rapid intraoperative tissue expansion: a preliminary report.

PURPOSE: Extensive scrotal skin loss can pose a difficult management problem. In most cases delayed scrotal approximation is feasible due to the redundancy of scrotal skin. However, large defects usually require reconstruction using flaps or grafts. We present a novel technique of scrotal closure using rapid intraoperative tissue expansion to manage select extensive partial scrotal defects. MATERIALS AND METHODS: Between January 1996 and April 2006, 3 patients underwent delayed closure using rapid intraoperative tissue expansion for approximately 75% scrotal skin loss. Intraoperatively the residual lateral scrotal and medial thigh skin, and subcutaneous tissues were dissected, creating bilateral cavities for the placement of round 300 cc tissue expanders. Gradual inflation for a total of 20 minutes allowed adequate tissue expansion of the 2 thigh flaps, enabling tension-free scrotal closure. RESULTS: Each patient was followed for 12 months. The resulting reconstruction provided a tension-free, cosmetically appealing scrotum with complete testicular coverage. There were no perioperative or postoperative complications. CONCLUSIONS: Although rapid intraoperative tissue expansion has been successfully used for the closure of facial and extremity defects, to our knowledge it has not been described for genital skin loss. Our experience suggests that this relatively simple method is a viable addition to the reconstructive armamentarium in a select group of patients with extensive scrotal skin defects that are not amenable to scrotal approximation alone.

Influence of prostate volume and percent free prostate specific antigen on prostate cancer detection in men with a total prostate specific antigen of 2.6 to 10.0 ng/ml.

PURPOSE: Percent free prostate specific antigen and prostate specific antigen density have been independently shown to increase the specificity of prostate cancer screening in men with prostate specific antigen levels between 4.1 and 10.0 ng/ml. Recent data suggest the total prostate specific antigen cutoff for performing a biopsy should be 2.6 ng/ml. We assessed the influence of percent free prostate specific antigen and prostate volume on cancer detection in men with a prostate specific antigen between 2.6 and 10.0 ng/ml. MATERIALS AND METHODS: From 1991 to 2005 all transrectal ultrasound guided prostate biopsies (5,587) for abnormal digital rectal examination and/or increased age specific prostate specific antigen were evaluated. A total of 1,072 patients with a prostate specific antigen between 2.6 and 10.0 ng/ml and any percent free prostate specific antigen were included in study. The cancer detection rate was calculated for each percent free prostate specific antigen/volume stratum. RESULTS: Prostate cancer was detected in 296 patients (27.6%). The mean age and prostate specific antigen of the patients with benign pathology and prostate cancer were similar. Mean percent free prostate specific antigen was 17.5% and 14.1% (p>0.05), and the mean volume was 62.0 and 46.0 cc (p=0.001), respectively. The strongest risk factors for a positive biopsy were percent free prostate specific antigen (odds ratio 0.004, p<0.001), volume (OR 0.977, p<0.001) and digital rectal examination (OR 1.765, p=0.007), but not total prostate specific antigen (p=0.303). When stratified by volume and percent free prostate specific antigen, distinct risk groups were identified. The probability of detecting cancer inversely correlated with prostate volume and percent free prostate specific antigen. CONCLUSIONS: In men with prostate specific antigen levels between 2.6 and 10.0 ng/ml, the probability of detecting cancer was inversely proportional to prostate volume and percent free prostate specific antigen. This table may assist in predicting patient risk for harboring prostate cancer.

Preliminary report on use of AlloDerm for closure of intraoral defects after buccal mucosal harvest.

The ideal method for managing the intraoral defect after harvesting buccal mucosa for urethral reconstruction has not been clearly established. We describe a novel technique using AlloDerm to cover the harvest site, providing a simple means for a potentially less painful tension-free closure.

Extracorporeal shock wave lithotripsy success based on body mass index and Hounsfield units.

OBJECTIVES: To determine whether body mass index (BMI) and Hounsfield units (HUs) could be used as independent predictors of stone-free status after extracorporeal shock wave lithotripsy (ESWL). No detailed studies have assessed BMI as an independent predictor of ESWL outcome. Some studies have suggested that HUs of urinary calculi on noncontrast computed tomography may predict the stone-free rate after ESWL. METHODS: We evaluated 100 patients who had undergone ESWL for 5-mm to 10-mm upper urinary tract stones. The BMI was calculated for each patient. HU determination and chemical analysis was performed for each stone. Radiographic assessment at 6 weeks categorized patients into a stone-free (SF) or residual-stone (RS) group. Statistical analysis, using BMI and HUs as predictors, was performed to assess the stone-free rate after ESWL. RESULTS: Of 100 patients, 72 were in the SF and 28 in the RS group. The mean BMI for the SF group was 26.9 +/- 0.5 versus 30.8 +/- 0.9 in the RS group (P <0.05). The difference in the mean HU values for the SF and RS groups was statistically significant (577.8 +/- 182.5 versus 910.4 +/- 190.2, respectively; P <0.05). A successful outcome was significantly related to BMI (odds ratio 1.34, 95% confidence interval 1.09 to 1.65, P <0.01) and HUs (odds ratio 1.01, 95% confidence interval 1.007 to 1.019, P <0.01). The following equation was formulated to compute the probability of treatment failure: 1/1 + 2.7(-z), where z = 0.294 BMI + 0.13 HU - 18.98. CONCLUSIONS: BMI and HUs were statistically significant independent predictors of stone-free rates after ESWL. We believe a predictive model of ESWL outcome may be formulated on the basis of these findings and may be used to select the preferred treatment option for patients with urinary calculi.

Efficacy of high-energy transurethral microwave thermotherapy in alleviating medically refractory urinary retention due to benign prostatic hyperplasia.

OBJECTIVES: To determine the efficacy of high-energy transurethral microwave thermotherapy (HE-TUMT) in treating patients with medically refractory complete urinary retention secondary to benign prostatic hyperplasia (BPH). METHODS: Between April 2000 and July 2003, 39 patients in urinary retention due to BPH were treated with HE-TUMT. A Foley catheter was reinserted after HE-TUMT and removed at 3 weeks for a voiding trial. Patients unable to void were recatheterized, and voiding trials were repeated at 2-week intervals. Patients were evaluated according to history and physical examination, prostate-specific antigen level, prostate volume, cystourethroscopy, International Prostate Symptom Score, quality of life score, peak uroflow, and postvoid residual. Success was defined as the ability to urinate after HE-TUMT without the need for further intervention. RESULTS: The mean (+/- SD) patient age was 72 +/- 9.3 years. Mean follow-up period was 18 +/- 10.2 months. Twenty patients (51%) were characterized as American Society of Anesthesiologists class III or higher. The mean prostate volume was 75.2 +/- 57.6 cm3. The mean length of time that patients were dependent on indwelling Foley catheters before HE-TUMT was 9.6 +/- 14.2 weeks. Thirty-two patients were able to void after HE-TUMT, for an overall success rate of 82%. Patients voiding successfully after HE-TUMT had a mean of 1.6 +/- 0.8 voiding trials and required catheters after HE-TUMT for a mean period of 4.1 +/- 2 weeks. Only 6 (15%) of the patients who were voiding were able to stop their medication for BPH. CONCLUSIONS: We found an encouraging success rate with HE-TUMT in relieving urinary retention in patients with BPH, including those with large prostate volumes. It is an acceptable option for patients who are considered high risk for surgery. Several patients required multiple voiding trials before spontaneous urination, which suggests that improvements in bladder outlet obstruction might require a prolonged period after HE-TUMT. Finally, many patients might require continued use of medications after HE-TUMT.

Ventral onlay buccal mucosal grafts for anterior urethral strictures: long-term followup.

PURPOSE: We present our long-term experience with buccal mucosal grafts, placed ventrally, for the treatment of anterior urethral strictures. MATERIALS AND METHODS: A total of 23 patients with anterior urethral strictures underwent urethral reconstruction using buccal mucosa as a ventral onlay graft, with 18 grafts placed in the bulbar and 5 in the penile urethra. All operations were performed in 1 stage by a single surgeon (NAA). Mean graft length was 4.9 cm (range 3 to 12). International Prostate Symptom Score and uroflowmetry were obtained preoperatively, at 3, 6 and 12 months postoperatively, and annually thereafter. Urethral imaging was obtained preoperatively, at catheter removal and selectively thereafter. RESULTS: Patients were followed for a mean of 50 months (range 17 to 94). Etiology of the strictures was instrumentation (in 9), idiopathic (in 9), prior hypospadias repair (in 2), urethritis (in 2) and trauma (in 1). Of the 23 patients 21 (91%) were previously treated for urethral stricture with a total of 59 procedures (mean 2.8 procedures per patient). Success, defined as normal voiding without any need for subsequent urethral manipulation, was achieved in 20 of 23 patients (87%). A distal anastomotic stricture developed in the remaining 3 patients, each managed with 1 internal urethrotomy. One of these patients continues to require monthly self-dilations. There were no fistulas or clinically perceptible graft sacculations. CONCLUSIONS: With long-term followup our series confirms the durability of ventrally placed buccal mucosal grafts for the treatment of anterior urethral strictures. This proven procedure results in a high success rate with few complications.

Iatrogenic bladder perforations: longterm followup of 65 patients.

BACKGROUND: We reviewed our experience with bladder perforations to better understand the causes of these injuries and to describe their management and its effect on longterm outcomes. STUDY DESIGN: Our bladder trauma database yielded 65 patients during a 12-year period, followed for a mean of 36 months, who had sustained iatrogenic bladder perforations. Endourologic procedures were excluded. Demographic data, surgical details, mechanism of injury, anatomic location, grading, diagnosis, management, and outcomes were assessed. RESULTS: Gynecologic procedures accounted for 40 perforations (61.5%), general surgical procedures for 17 (26.2%), and urologic procedures for 8 (12.3%). The type of gynecologic surgery included abdominal hysterectomy in 16 (40%), resection of a pelvic mass in 12 (30%), cesarean section in 10 (25%), and diagnostic laparoscopy in 2 (5%). Of the general surgical procedures, eight were for colon cancer (47.1%), six for diverticulitis (35.3%), and three for inflammatory bowel disease (17.6%); of the urologic injuries, six occurred during vaginal surgery and two during laparoscopy. Predisposing factors were identified in 52 patients (80%). Intraoperative urologic consultation was obtained in 63 of 65 patients, with prompt identification and repair. In two cases a concurrent left ureteral injury was identified and managed by reimplantation. The sole complication was a vesicovaginal fistula 2 months postoperatively, so the success rate for repair was 98.4%. CONCLUSIONS: Although infrequent, iatrogenic bladder perforations can occur during any pelvic, abdominal, or vaginal procedure. Prompt intraoperative recognition is paramount to ensure satisfactory outcomes. Adequate repair usually can be achieved simply by vesicorrhaphy, limiting unnecessary extravesical dissection. With this approach, morbidity can be minimized.

Hounsfield units on computerized tomography predict stone-free rates after extracorporeal shock wave lithotripsy.

PURPOSE: Studies suggest that HU values on non-contrast computerized tomography may predict the ability to fragment urinary calculi. We determined whether the HUs of in vivo urinary stones could be used to predict the stone-free rates after extracorporeal shock wave lithotripsy. MATERIALS AND METHODS: We evaluated 50 patients who underwent extracorporeal shock wave lithotripsy for 5 to 10 mm. upper urinary tract stones. Chemical analyses and HU calculations were performed for each stone and posttreatment radiographic assessment categorized patients into a stone-free or a residual stone group. Statistical analysis was performed using the Student t test to compare mean HU values in the 2 groups. RESULTS: Of the patients 32 (64%) were stone-free and 18 (36%) had residual stones. Mean values +/- SEM for the stone-free and residual stone groups were significantly different (551.20 +/- 46.66 versus 926.20 +/- 51.42 HU, p <0.0001). A total of 30 calculi (60%) were located in the ureter, including 21 in the stone-free group and 9 in the residual stone group with a mean value of 505.10 +/- 46.66 and 888.70 +/- 102.00 HU, respectively, which was significantly different (p = 0.0005). A total of 20 calculi (40%) were located in the kidney, including 11 in the stone-free group and 9 in the residual stone group with a mean value of 558.40 +/- 62.38 and 905.10 +/- 61.49 HU, respectively, which was significantly different (p = 0.001). CONCLUSIONS: These findings suggest that HU measurement of urinary calculi on pretreatment non-contrast computerized tomography may predict the stone-free rate. This information may be beneficial for selecting the preferred treatment option for patients with urinary calculi.

Influence of prostate volume in the detection of prostate cancer.

OBJECTIVES: To assess the influence of prostate volume on prostate cancer (CaP) detection in men who underwent repeated sextant transrectal ultrasound biopsy of the prostate. METHODS: Between September 1991 and September 2000, 4376 men underwent sextant transrectal ultrasound-guided biopsy of the prostate. Of the 4376 men, 556 underwent repeat biopsy because of persistent prostate-specific antigen elevation (greater than 4 ng/mL) and/or an abnormal digital rectal examination or suspicious pathologic findings. The percentage of CaP missed on the initial biopsy and detected on the repeat biopsy between arbitrary prostate volumes of less than 50 and 50 cm3 or greater and between less than 37.5 and 37.5 cm3 or greater, the median prostate volumes of men with CaP, were compared. Patient age, prostate-specific antigen level, digital rectal examination findings, and Gleason score in each volumetric cutoff group were also compared. RESULTS: CaP was detected in 22% of men who underwent a repeat biopsy. The percentage of CaP missed on the initial biopsy but subsequently detected on the repeat biopsy consistently increased as the volume increased. A statistically significant difference in the percentage of CaP not detected on the initial biopsy was found between prostate volumes of less than 50 and 50 cm3 or greater and between less than 37.5 and 37.5 cm3 or greater (P <0.05). No statistically significant difference in prostate-specific antigen, age, digital rectal examination, or Gleason score was found between each volumetric cutoff group. CONCLUSIONS: A significant percentage of men are diagnosed with CaP after a repeat biopsy. We have demonstrated that the percentage of CaP missed on the initial biopsy and detected on the repeat biopsy increases as the prostate volume increases. The results of our study suggest that in men with large prostates, traditional sextant biopsies may not be adequate to detect CaP.

The effect of finasteride on the expression of vascular endothelial growth factor and microvessel density: a possible mechanism for decreased prostatic bleeding in treated patients.

PURPOSE: Several studies have confirmed the benefit of finasteride in limiting hematuria from benign prostatic hyperplasia. Vascular endothelial growth factor (VEGF), a potent stimulator of angiogenesis, and microvessel density have been independently evaluated in the mechanism of decreased bleeding observed in patients treated with finasteride. We evaluated the expression of VEGF and suburethral prostatic microvessel density in patients with benign prostatic hyperplasia treated with finasteride. MATERIALS AND METHODS: The study included 24 patients undergoing prostatic surgery for benign disease, of whom 12 were given finasteride for a minimum of 6 weeks before surgery and the remaining 12 served as controls. Sections from the prostatic urothelium and hyperplastic prostate were individually stained for CD34 specific for nascent blood vessels and VEGF. Analysis of each specimen was performed in a blinded fashion. Microvessel density was calculated by counting the number of positively stained blood vessels on 10 consecutive, nonoverlapping, high power fields within the suburethral and hyperplastic prostate compartments. VEGF expression was examined by immunohistochemistry. Statistical analysis of the results was performed using Student's t test. RESULTS: Prostatic suburethral VEGF expression and microvessel density were significantly lower in the finasteride group compared to controls (p <0.05). Differences in VEGF expression and microvessel density at the level of the hyperplastic prostate were not found to be significantly different between the 2 groups. CONCLUSIONS Decreased expression of VEGF by finasteride inhibits angiogenesis and significantly decreases microvessel density in prostatic suburethral tissue. This sequential relationship provides histochemical insight into the mechanism by which finasteride reduces prostatic urethral bleeding.

Decreased suburethral prostatic microvessel density in finasteride treated prostates: a possible mechanism for reduced bleeding in benign prostatic hyperplasia.

PURPOSE: We evaluated the influence of finasteride on prostatic microvessel density to elucidate a mechanism of decreased bleeding in finasteride treated patients with hematuria secondary to benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 22 patients with clinical BPH and gross hematuria who underwent prostate reductive surgery between 1998 and 2000 were prospectively evaluated. The prostate from 10 finasteride treated and 12 untreated patients was immunohistochemically stained for CD-34. Microvessel density analysis was performed by quantifying positive stained blood vessels located within the stroma of hyperplastic nodules as well as in the suburethral portion of the prostate. RESULTS: Mean microvessel density plus or minus standard deviation in finasteride treated patients was significantly lower in the suburethral portion of the prostate versus untreated controls (14.0 +/- 2.8 versus 20.2 +/- 5.3 vessels per high power field, p <0.05). In the nodular hyperplasia there was no statistically significant difference in the treatment and control groups (mean 17.5 +/- 2.8 and 16.7 +/- 4.6 vessels per high power field, respectively). CONCLUSIONS: Finasteride significantly decreases suburethral prostatic microvessel density in patients with BPH, which may explain its efficacy for decreasing BPH associated bleeding.