Role of the Apparent Diffusion Coefficient as a Predictor of Tumor Progression in Patients with Chordoma.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging may aid in distinguishing aggressive chordoma from nonaggressive chordoma. This study explores the prognostic role of the apparent diffusion coefficient in chordomas. MATERIALS AND METHODS: Sixteen patients with residual or recurrent chordoma were divided postoperatively into those with an aggressive tumor, defined as a growing tumor having a doubling time of <1 year, and those with a nonaggressive tumor on follow-up MR images. The ability of the ADC to predict an aggressive tumor phenotype was investigated by receiver operating characteristic analysis. The prognostic role of ADC was assessed using a Kaplan-Meier curve with a log-rank test. RESULTS: Seven patients died during a median follow-up of 48 months (range, 4-126 months). Five of these 7 patients were in the aggressive tumor group, and 2 were in the nonaggressive tumor group. The mean ADC was significantly lower in the aggressive tumor group than in the nonaggressive tumor group (P = .002). Receiver operating characteristic analysis showed that a cutoff ADC value of 1.494 × 10-3 × mm2/s could be used to diagnose aggressive tumors with an area under the curve of 0.983 (95% CI, 0.911-1.000), a sensitivity of 1.000 (95% CI, 0.541-1.000), and a specificity of 0.900 (95% CI, 0.555-0.998). Furthermore, a cutoff ADC of ≤1.494 × 10-3 × mm2/s was associated with a significantly worse prognosis (P = .006). CONCLUSIONS: Lower ADC values could predict tumor progression in postoperative chordomas.

Non-secretor status is associated with female acute uncomplicated pyelonephritis.

OBJECTIVE: To retrospectively analyse the secretor status in women with acute uncomplicated pyelonephritis, as non-secretors of histo-blood group antigens are reportedly at risk of recurrent urinary tract infections (UTIs). PATIENTS AND METHODS: The study included 245 women who had been diagnosed as having acute uncomplicated pyelonephritis in affiliated hospitals over the past 5 years. All women were sent antiseptic swabs, to collect saliva, and a questionnaire to survey their past UTI episodes and menstrual status. Responses with written informed consent were obtained from 106 women (median age 50.5 years, range 17-85). The secretor status was determined using the haemagglutination inhibition assay from the saliva on the swabs. RESULTS: Forty-four (41%) of the women were non-secretors, a significantly higher frequency than in the (control) Japanese population (217 of 960, 22.6%; P< 0.001). The incidence of non-secretors was significantly higher (P < 0.01) in premenopausal (26 of 46, 57%) than in postmenopausal women (18 of 60, 30%). CONCLUSION: These results suggest that non-secretor status is associated with a genetic susceptibility to acute uncomplicated pyelonephritis, especially in premenopausal women.

Molecular epidemiological evidence for ascending urethral infection in acute bacterial prostatitis.

PURPOSE: To test the ascending urethral infection in the pathogenesis of acute bacterial prostatitis, we assessed the clonality of Escherichia coli strains isolated from urine and rectal swab of patients with acute bacterial prostatitis using molecular typing methods. MATERIALS AND METHODS: A total of 50 E. coli strains each isolated from urine and rectal swabs of 9 men with acute bacterial prostatitis at diagnosis were examined for 6 urovirulence determinant profiles and pulsed field gel electrophoresis patterns. In 1 case E. coli isolates from the rectal swab of the patient's wife were also examined at diagnosis and after 5 weeks. RESULTS: The urovirulence profile and pulsed field gel electrophoresis demonstrated that causative E. coli was monoclonal in each case, and present in the rectal swab as a predominant (96% to 100%) fecal clone in 2 and a minority clone (2% to 8%) in 4. Furthermore, causative E. coli dominated in the rectal swab of the 1 patient's wife. CONCLUSIONS: Our results are consistent with the ascending route of infection in acute bacterial prostatitis. However, causative E. coli might possibly originate from either intestinal reservoir of the host or household member. Owing to limitations of the cross-sectional design of this study, longitudinal studies are necessary to establish the ascending route of infection in this disease.

Changes in resistive index following extracorporeal shock wave lithotripsy.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) has replaced most surgical and endourologic forms of therapy for upper urinary tract stone disease. Despite its proved safety and efficacy, its adverse effects on renal function are still to be identified. A newer diagnostic technique, color Doppler ultrasonography, has brought a new insight into renal function. It enables precise evaluation of the renal vascular supply. Changes in intrarenal vascular resistance after ESWL were studied with Doppler ultrasound techniques. METHODS: In 70 consecutive patients the resistive index (RI) was measured at an interlober artery before and 30 min after ESWL in the treated and contralateral kidneys. In 17 patients, a follow-up Doppler study was performed 1 week after ESWL. RESULTS: In the treated kidneys, the RI significantly increased from 0.656+/-0.053 (mean +/- SD) at baseline to 0.682+/-0.053 (P<0.0001). There was no significant correlation of increase in RI with patient age (r = 0.010) or with pre-ESWL blood pressure (r = 0.002). Elderly patients (> or =60 years old, n = 31) had higher RI levels on baseline than younger patients (<60 years old, n = 39). In 18 of the 31 (58.1%) elderly cases the RI were elevated to greater than 0.7, indicating pathologic changes. In younger patients, only 9 (23.1%) experienced increase in RI up to 0.7 or greater. The contralateral untreated kidneys showed significant change in RI before (0.664+/-0.045) and after (0.679+/-0.049) lithotripsy in elderly patients (P<0.005). A follow-up Doppler study showed that the mean RI returned to pretreatment levels after 1 week. CONCLUSIONS: Because of higher RI levels on baseline, elderly patients have a higher risk of post-ESWL renal tissue damage than younger patients. Clinical implication of RI change in the contralateral kidneys in this study remains to be answered. The measurement of changes in RI with Doppler ultrasound techniques after ESWL may provide useful information for clinical diagnosis of renal tissue damage.

Virulence characteristics of Escherichia coli in acute bacterial prostatitis.

To assess the urovirulence characteristics of Escherichia coli strains causing acute prostatitis, urinary isolates from men with acute prostatitis (n=107) and from women with acute uncomplicated pyelonephritis (n=76) were examined for the prevalence of sfa, foc, and 3 papG allele genotypes and phenotypes and for the production of alpha-hemolysin and cytotoxic necrotizing factor 1. The papG allele III and foc gene were found more frequently and the papG allele II less frequently among prostatitis than from pyelonephritis isolates. A higher proportion of hly+ cnf1+ genotype in prostatitis strains (64% vs. 36%) was particularly striking. Both prostatitis and pyelonephritis strains expressed virulence factors similarly except for a higher proportion of nonhemolytic prostatitis isolates. Although the pathogenetic mechanisms of urinary tract infections in men and women may differ, virulence factors such as adhesins and cytotoxins may have important roles in the pathogenesis of acute prostatitis.

[The advance of ultrasound guided prostate biopsy--comparison between 4 quadrant and 6 sextant biopsy].

Although systematic biopsy has increased the detection rate of prostate cancer, the optimal method of biopsy has not yet been fully established. The number and site of cores, and the biopsy route are controversial in terms of cancer detection and complication. We briefly review the advances in prostate biopsy, and present the results of our biopsy methods. Our study showed that the difference of cancer detection rate between 4 quadrant and 6 sextant biopsy was not significant. There was little value in systematic transition zone biopsies. However, such biopsies proved useful in patients whose first systematic biopsies was negative and who have persistently elevated PSA values. It is recommended that the biopsy protocol for routine prostate cancer detection be targeted to the peripheral zone.

Free-to-total prostate specific antigen ratio in clinical staging of prostate cancer.

The value of the free-to-total serum prostate-specific antigen (f/t PSA) ratio was compared with that of the total prostate specific antigen (tPSA) value for the prediction of clinical stage in patients with prostate cancer. The f/t PSA ratio was obtained from the frozen sera of 56 untreated patients with histologically proven BPH and 78 patients with prostate cancer. The clinical stage was organ-confined in 36, locally advanced in 20 and metastatic in 22 patients. Serum levels of free PSA (fPSA) and tPSA were determined using a chemiluminescent enzyme immunoassay. The f/t PSA ratio was calculated by dividing the fPSA value by the tPSA value and was compared with tPSA and fPSA in the correlation with clinical stage via the Spearman rank correlation test. Patients with prostate cancer had a significantly lower f/t PSA ratio than patients with BPH. The f/t PSA ratio did not differ between patients with clinically localized and metastatic cancer. tPSA and fPSA reflected the clinical stage and the extent of bone metastasis more accurately than the f/t PSA ratio. The extent of bone metastasis had no effect on the PSA ratio. The f/t PSA ratio had no additional value in clinical staging compared to tPSA. Our study suggests that the f/t PSA ratio does not reflect tumor load.

Prostate specific antigen adjusted for the transition zone volume as an indicator of prostate cancer.

PURPOSE: We compared prostate specific antigen (PSA) adjusted for the transition zone volume with PSA and PSA density with regard to value in diagnosing prostate cancer in men with intermediate PSA levels of 4.1 to 10.0 ng./ml. in a community based urology practice. MATERIALS AND METHODS: Between October 1994 and May 1996, PSA transition zone was obtained from 92 of 94 men who underwent systematic sextant biopsies and had a PSA value between 4.1 and 10.0 ng./ml. PSA transition zone, calculated by dividing the PSA value by the volume of the transition zone of the prostate, was compared with PSA and PSA density via the receiver operating characteristic (ROC) curves. RESULTS: Of the 92 men 12 (13.0%) had prostate cancer. ROC curve analysis demonstrated that PSA transition zone and PSA density predicted the biopsy outcome significantly better than PSA (p <0.05 and p <0.01, respectively). In a subset of 59 men with normal digital rectal examination PSA transition zone predicted the biopsy outcome better than PSA density, although without significant difference. With a cutoff value of 0.3 PSA transition zone had a sensitivity of 75% and a specificity of 54%. CONCLUSIONS: PSA transition zone is more specific than PSA in distinguishing benign from malignant disease in men with intermediate PSA levels of 4.1 to 10.0 ng./ml., especially in those with normal digital rectal examination. Further study is necessary to discuss whether PSA transition zone is superior to PSA density.

Nerve-sparing retroperitoneal lymph node dissection for metastatic testicular cancer.

BACKGROUND: Nerve-sparing techniques are used during retroperitoneal lymph node dissection (RPLND) in patients with early stage testicular cancer to preserve postoperative ejaculatory function. Indications for the procedures have been extended to patients with a postchemotherapy retroperitoneal residual mass without compromising the efficacy of surgery. We report 6 cases diagnosed with metastatic testicular cancer who underwent nerve-sparing RPLND. METHODS: Between January 1994 and March 1996, 6 patients with metastatic testicular cancer underwent nerve-sparing RPLND. Five of these patients received primary chemotherapy and a retroperitoneal residual mass. Four patients underwent complete bilateral RPLND and 2 underwent unilateral template surgery. RESULTS: After a mean follow-up of 18.7 months (range, 8 to 34), there have been no local recurrences and 5 (83%) patients report antegrade ejaculation. CONCLUSION: Nerve-sparing RPLND is applicable for selected patients with metastatic testicular cancer without increasing the risk of local recurrence. Ejaculatory function is preserved in the majority of patients, contributing to the improvement of the quality of life in men who require such surgery.

Prospective evaluation of prostate specific antigen density and systematic biopsy for detecting prostate cancer in Japanese patients with normal rectal examinations and intermediate prostate specific antigen levels.

PURPOSE: To improve the specificity of cancer detection in patients with normal digital rectal examination and intermediate prostate specific antigen (PSA) level, PSA density has been recommended, with biopsy based on a PSA density of 0.15 or more. PSA density is reportedly higher in Japanese men than in white men, because of physiological differences between the 2 races. We prospectively evaluated PSA density as a discriminator of prostate cancer in Japanese men. MATERIALS AND METHODS: We evaluated prospectively 60 consecutive men with normal digital rectal examinations and serum PSA levels of 4.1 to 10.0 ng./ml. enrolled during a 17-month period. All patients underwent transrectal ultrasound guided sextant biopsies, regardless of calculated PSA density and transrectal ultrasound findings. Serum PSA levels were determined by IMx assay. RESULTS: Overall, 8 of 60 men (13%) had prostate cancer. There was no significant difference in mean PSA between those with positive and those with negative biopsies, but the difference was significant in the mean PSA density (mean 0.24 and 0.15, respectively, p < 0.01). Receiver operating characteristics curves for PSA and PSA density demonstrated superior benefit for PSA density in this patient population. A reference PSA density value of 0.19 was chosen because it showed the highest sum of sensitivity and specificity, which gave a sensitivity of 75%, a specificity of 87%, a positive predictive value of 46% and a negative predictive value of 96%. CONCLUSIONS: The results suggest that PSA density improves the specificity of cancer detection in men with a normal digital rectal examination and an intermediate PSA level. Although further study with a larger patient population is needed to obtain a best-fit value, an optimal PSA density cutoff seems to be higher than that recommended in the literature from western countries. Because of possible racial differences in serum PSA and prostate volume, the role of PSA density in Asian men should be studied independently.

[Intrarenal bacillus Calmette-Guerin therapy for carcinoma in situ of the upper urinary tract].

PURPOSE: We performed intrarenal bacillus Calmette-Guerin (BCG) instillation for carcinoma in situ (CIS) of the upper urinary tract. Its efficacy and safety are evaluated. MATERIAL AND METHODS: Eight patients (6 men and 2 women, median age of 63.7 years) diagnosed as upper urinary tract carcinoma in situ were studied. One had bilateral upper urinary tract CIS. Thus, 9 units of upper urinary tract were treated with BCG instillation. Diagnostic criteria of upper urinary tract CIS were: 1. positive voided urinary cytology, 2. negative multiple random biopsy of the bladder and the prostatic urethra, 3. negative radiographic studies, 4. two serial positive cytologies in selective ipsilateral urine sampling. The BCG solution was administered weekly by retrograde ureteral catheterization under local anesthesia and instillation during one hour. Second course instillation was performed when 1st course was not effective. RESULTS: Of 9 renal units 7 (78%) had normalization of the urinary cytology at the end of the 1st course BCG therapy. One patient with CIS of the bilateral upper tract had negative cytology of the unilateral unit, and underwent the contralateral nephroureterectomy because of persistent positive urinary cytology and coincidental renal cell carcinoma. One patient did not have negative cytology even after three courses of BCG instillation and is now under observation. During the procedure, high fever and bladder irritative symptom were observed in 6 out of the 8 patients (75%) and 4 (50%), respectively. CONCLUSIONS: Although longer followup and further experience with intrarenal BCG are required, this treatment is considered to be effective and safe for upper tract CIS.

Value of systematic transition zone biopsy in the detection of prostate cancer.

BACKGROUND: We evaluated routine transition zone biopsies for the detection of prostate cancer. METHODS: Systematic sextant transrectal biopsies, including 2 systematic transition zone biopsies (sextant biopsy group), were performed on 196 consecutive patients. Biopsies were based on indications from digital rectal examination and/or a serum PSA level greater than 4.0 ng/mL. During the same period, 21 patients with persistently elevated PSA levels and earlier negative systematic biopsies also had the sextant biopsy (re-biopsy group). The sextant biopsy group was compared with 124 cases in our previous cancer detection program who had systematic quadrant biopsies targeted to the peripheral zone (quadrant biopsy group). RESULTS: Between the sextant and quadrant biopsy groups, the difference in rate of cancer detection was not significant statistically. Of the sextant biopsy group, 64 (33%) demonstrated malignancy, including 9 (4.6%) with cancer found exclusively in the peripheral zone and 55 (28%) both in the peripheral and transition zones. No cancer was found exclusively in the transition zone. Of the re-biopsy group, all 4 cancers (19%) were detected in the transition zone, 2 of them exclusively in the transition zone. CONCLUSION: Routine transition zone biopsies did not increase the detection rate of prostate cancer. Systematic transition zone biopsies proved useful to the patients with persistently elevated PSA values and negative results in previous systematic peripheral zone biopsies.

Pros-Eight transurethral radiofrequency thermotherapy for benign prostatic hyperplasia: preliminary clinical results.

BACKGROUND: We have developed a new transurethral thermotherapy device using 8MHz radiofrequency (RF) for the treatment of patients with symptomatic benign prostatic hyperplasia (BPH). We report the safety and effectiveness of the initial clinical experience with this device. METHODS: Sixty patients with symptomatic BPH were subjected to a single 1-hour treatment under local anesthesia. The treatment device uses extracorporeal RF capacitive heating in combination with radiative heating and conductive cooling of the urethra. RESULTS: In the 49 patients evaluable at 3 months, the mean International Prostate Symptom Score decreased from 17.8 to 13.1 (P < 0.0001) and the Quality of Life score decreased from 4.4 to 3.4 (P < 0.0005). Maximum flow rate increased from 8.1 to 9.7 mL/s (P < 0.05) at 3 months. Overall effectiveness by Homma's response criteria was as follows; excellent 4.1%, good 10.2%, fair 38.8% and poor 46.9%. Side effects were minimal. Gross hematuria was seen in 3 patients and erosion of the external urethral meatus was seen in 2 patients, but none had urinary retention. CONCLUSIONS: In this initial clinical trial, transurethral RF thermotherapy was safe and resulted in modest symptomatic improvement. Further investigations for optimizing the treatment protocol seem warranted.

Radical prostatectomy for clinically localized prostate cancer: local tumor extension and prognosis.

BACKGROUND: This study was performed to evaluate the frequency of local tumor extension and its effect on disease progression after radical prostatectomy. METHODS: The study consisted of 66 consecutive men who underwent radical prostatectomy for clinically localized prostate cancer without any prior hormonal therapy. Cases were stratified according to pathologic findings. Sites of capsular penetration were also evaluated. RESULTS: The overall incidences of lymph node metastases, seminal vesicle invasion, capsular penetration, and positive surgical margin were, respectively, 23%, 32%, 55% and 35%. The disease progression rate in patients with positive lymph nodes differed significantly from that in those without nodal metastases (P < 0.0001). Although seminal vesicle invasion, capsular penetration, or positive surgical margin had an adverse effect on prognosis, the difference in progression missed statistical significance, when patients with positive lymph node metastases were excluded. The most common site of capsular penetration was posterolateral, in the area of the neurovascular bundle. CONCLUSIONS: Extraglandular tumor extension and positive surgical margins are common features of radical prostatectomy specimens. A nerve-sparing operation should be performed selectively and with great caution. The markedly adverse effect of lymph node involvement on progression must be accounted for when evaluating other variables relating to progression.

Pyogenic vertebral osteomyelitis after acute bacterial prostatitis: a case report.

A case of pyogenic vertebral osteomyelitis after acute bacterial prostatitis in a 78-year-old man is reported. The rarity and subtle clinical presentation of this condition, and the delayed appearance of radiologic signs of progression to destructive osteomyelitis, contributed to a significant delay in diagnosis. An arterial blood culture positive for bacterial growth during the episode of acute prostatitis suggested that bacteremia might result from hematogenous spread of the infection to the vertebral column via the venous system. Since intensive antimicrobial therapy proved ineffective, debridement of the first and second lumbar vertebral bodies, and anterior spinal fusion from the twelfth thoracic to the third lumbar vertebrae were performed. The patient's high fever and severe lumbago subsided immediately after the surgery. The possibility of development to pyogenic vertebral osteomyelitis should be kept in mind when treating a serious genitourinary tract infection.

Transurethral interstitial laser coagulation for benign prostatic hyperplasia: treatment outcome and quality of life.

OBJECTIVE: To assess the efficacy and safety of transurethral interstitial laser coagulation (ILC) in the treatment of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: From December 1993 to March 1995, 61 patients (mean age 69.7 years, range 55-89) with symptomatic BPH were treated with ILC. A neodymium: YAG laser was used in combination with specially designed interstitial thermotherapy light-guides. The tip of the light guide was inserted repeatedly into each lobe of the prostate transurethrally, under direct vision. The number of fibre placements depended on the size and configuration of the gland. The prostatic urethra was preserved during the procedure. Treatment outcome was evaluated using the International Prostatic Symptom Score (IPSS), measurement of urinary flow rate and post-void residual urine volume (PVR). The disease-specific quality of life (QOL) was assessed using a QOL assessment score and a BPH impact index. Independently of the symptom assessment, a self-reporting questionnaire was completed 3 months after treatment to determine the patients' satisfaction with the treatment and their sexual function. RESULTS: Among the 31 patients followed for 6 months, the mean IPSS decreased significantly, from 18.9 at baseline to 7.7 (59% improvement; P < 0.001), the mean peak flow rate increased from 6.7 mL/s to 10.0 mL/s (49% improvement; n = 29; P < 0.001), the mean PVR decreased from 119 mL to 29 mL (76% improvement; n = 28, P < 0.001) and the mean prostate volume decreased significantly, from 37.1 mL to 31.6 mL (15% reduction at 3 months; n = 52, P < 0.001). There was a steady and progressive improvement in both the QOL assessment and the BPH impact index scores at 3 and 6 months. More than 90% of the patients reported satisfaction with the treatment and none reported the new onset of erectile dysfunction. There were no serious side-effects, except for two cases of loss of ejaculation. CONCLUSIONS: The early clinical results suggest that the ILC procedure is a safe and effective less-invasive treatment for BPH that appears to have favourable effects on the patients' quality of life.

Interstitial laser coagulation for benign prostatic hyperplasia: preliminary clinical results.

We report our early experience in the clinical application of interstitial laser coagulation of the prostate (ILCP) in the treatment of benign prostatic hyperplasia (BPH). Neodymium: YAG laser energy is transmitted via a specially designed interstitial thermotherapy light-guide. The light guides were inserted transurethrally into each lobe of the prostate by direct puncture, under direct visualization. The prostatic urethra is preserved during the procedure. From December 1993 to March 1994, 37 patients with symptomatic BPH were treated with ILCP. Treatment outcome was evaluated by the International Prostatic Symptom Score (I-PSS), flow rate, postvoided residual urine volume and quality of life score. Significant improvement in I-PSS and peak flow rate was observed at 3 months: I-PSS decreased from a mean of 19.3 to 10.4, and the peak flow rate increased from a mean of 7.2 to 9.4 ml/sec (p < 0.0001). The mean postvoided residual urine volume significantly decreased from 91 to 47 ml (p < 0.01). Two days after ILCP the serum prostate-specific antigen had increased by 860%, evidence of the significant tissue damage produced by laser irradiation. The quality of life score significantly decreased from a mean of 4.8 to 2.1 (p < 0.0001). No serious side-effects were observed. The early clinical results suggest that ILCP is safe and effective as a treatment of BPH and is less invasive than some other methods.