Ureterocele associated with ureteral duplication and a nonfunctioning upper pole segment: management by partial nephroureterectomy alone.

We reviewed the records of 87 patients with a ureterocele associated with duplication and a nonfunctioning upper pole segment. All patients involved in this study were treated by partial nephroureterectomy and observation. Additional surgery to correct vesicoureteral reflux became necessary in 54 cases (62%). A careful retrospective chart and radiographic review identified that the need for additional surgery was directly related to the number of renal moieties that had a ureterocele or vesicoureteral reflux present. In particular, when a ureterocele alone was present 21 of 21 patients (100%) did not require additional surgery. When low grade (less than 3/5) reflux was present into 1 ureter 8 of 15 patients (60%) did not require surgery. The presence of high grade reflux into 1 moiety or vesicoureteral reflux into more than 1 moiety, regardless of the grade of reflux, almost inevitably resulted in the need for further surgery with only 2 of 50 patients (4%) with these abnormalities cured by partial nephroureterectomy alone. Our data suggest that this latter group of patients may be treated more efficaciously by complete genitourinary reconstruction rather than partial nephroureterectomy alone.

Laser treatment of benign prostatic hyperplasia.

With the increasing longevity of the population, the incidence of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia (BPH) is expected to increase. Transurethral resection of the prostate (TURP) is currently considered the standard surgical treatment for this disease. However, TURP is an invasive procedure associated with some morbidity and, rarely, mortality. During the past several years, several alternative treatments for BPH have emerged. Visual laser ablation of the prostate (VLAP) is one of the more attractive choices among these alternatives. The use of laser energy to treat BPH has several advantages over TURP. Laser energy causes coagulation of the blood vessels, thus minimizing blood loss and fluid absorption. VLAP is an outpatient procedure performed under direct vision utilizing a standard or continuous-flow cystoscope. The technique of VLAP is relatively easily learned and has a much shorter learning curve than that of TURP. To date, clinical trials have confirmed the efficacy and safety of VLAP and the minimal associated morbidity. In the short-term follow-up, improvement in both subjective (symptom score) and objective (urinary flow rate) factors is similar to that after TURP. Although the results obtained with this laser technology are exciting and encouraging, further study and long-term follow-up are needed to confirm the durability of these results.

Effect of cystoscopy, prostate biopsy, and transurethral resection of prostate on serum prostate-specific antigen concentration.

To assess the effect of cystoscopy, prostate biopsy, and transurethral resection of the prostate (TURP) on the serum prostate-specific antigen (PSA) concentration, 101 patients were evaluated. For cystoscopic examination, 69 men were randomized in a prospective manner to one of three groups: flexible cystoscopy, rigid cystoscopy, and a control cohort. The median change in serum PSA was 0.1 ng/mL following flexible cystoscopy, 0.05 ng/mL after rigid cystoscopy, and 0.05 ng/mL for the control group, in which two serum PSA determinations were obtained without an intervening cystoscopy. The differences between the three groups were not statistically significant. The effect of prostate biopsy and TURP was examined in 32 men. Prostate biopsy caused an immediate elevation in the serum PSA level, with a median increase of 7.9 ng/mL (p < 0.0001). Similarly, TURP produced an elevation in the serum PSA concentration, with a median change of 5.9 ng/mL (p < 0.001). The median time required for the serum PSA value to return to a stable level after prostate biopsy was fifteen days (range: 5-21 days) for men with prostate cancer and seventeen days (range: 3-30+ days) for men without cancer, and eighteen days (range: 12-30+ days) for men who underwent TURP. These findings indicate that a serum PSA determination after either a flexible or a rigid cystoscopy is accurate and reliable. Both biopsy and TURP cause an immediate increase in the serum PSA level, which usually returns to a stable, baseline level within three weeks. However, because in some patients the serum PSA still remained elevated after four weeks, it is recommended that a serum PSA determination not be obtained for at least six weeks after either a prostate biopsy or TURP.

Sustained, substantially increased concentration of prostate-specific antigen in the absence of prostatic malignant disease: an unusual clinical scenario.

A 60-year-old man had a persistent, marked increase in the serum concentration of prostate-specific antigen (more than 20 times the upper limit of the reference range) and no identifiable prostatic malignant involvement. To our knowledge, this is the first such case reported in the literature. Possible explanations for this increased value are described, and nonmalignant conditions that can increase serum concentrations of prostate-specific antigen are reviewed.

Prostate-specific antigen: establishment of the reference range for the clinically normal prostate gland and the effect of digital rectal examination, ejaculation, and time on serum concentrations.

This study investigated the serum prostate-specific antigen concentration in 100 healthy men (mean age, 26.3 years; range, 20-29 years) with a clinically normal prostate gland. The effect of digital rectal examination and ejaculation on the serum concentration, and the variability of the serum concentration over 1-week and 1-month periods were examined. In the 100 subjects, the serum prostate-specific antigen concentration ranged from less than 0.1-2.6 ng/ml. The mean, median, and mode were 0.68 ng/ml, 0.6 ng/ml, and 0.4 ng/ml, respectively. The 97.5th percentile value was 2.1 ng/ml. The mean and median changes in the serum concentration after digital rectal examination were -0.013 +/- 0.11 ng/ml and 0.0 ng/ml, respectively (P = 0.59 compared with control group). The mean change after ejaculation was 0.05 +/- 0.12 ng/ml, and the median change was 0.0 ng/ml (P = 0.14 compared with control group). Diurnal variation showed minimal change in 16 patients over a 1-week period. The mean change (p.m. value-a.m. value) was 0.003 ng/ml (range, -0.2-0.06 ng/ml). In addition, the serum concentration showed minimal intrapatient variability in 20 patients throughout a 1-month period; the average coefficient of variation (standard deviation/mean) in these subjects was 16.5% (range, 6.4-45.2%). These results indicate that the range in the serum concentration of prostate-specific antigen for healthy men with a clinically normal prostate gland is significantly lower (0.0-2.6 ng/ml) than the currently employed range (0.0-4.0 ng/ml; Tandem-R PSA assay); in addition, digital rectal examination and ejaculation have no significant effect on the serum concentration. Finally, the time of day has little effect, and the variability in the serum concentration of prostate-specific antigen over a 1-week and 1-month interval is minimal.