Bladder tumor markers: need, nature and application. 1. Nucleus-based markers.

Urothelial tumors are common: their diagnosis and long-term management represent a large part of most urologists' workload. The majority of such tumors are 'superficial' and are mostly managed by repeated cystoscopic surveillance and treatment. A smaller but significant group of patients either start with, or subsequently progress to, more invasive disease, thus requiring an alternative and more invasive treatment. Maximizing the benefit/risk ratio of the diagnosis and the various treatment options of bladder tumors requires the availability of a reliable tumor marker. The concept of tumor markers encompasses the utilization of any detectable deviation from normality that is indicative of neoplasia. For bladder cancer, most of these markers are present in urine. In this part of the review we examine, from the clinician's point of view, the literature verdict on older techniques such as cytology and cytometry, as well as the current status of new nucleus-based tests such as P53, telomerase, NMP22 and Ki67.

Bladder tumor markers: need, nature and application. 2. Tumor and tumor-associated antigens.

Despite the diversity of the available markers, none is truly specific to transitional epithelium, let alone its tumors. Some of the markers used, such as hCG and CEA, are far better known in other fields and seem to be expressed in only a minority of urothelial tumors. The majority of the available markers are tumor associated and should perhaps be considered as by-products of the process of malignancy in the urinary tract. Newer tests which are simple, rapid and easy to use have a practical advantage. These are currently the Bard BTA, BTA Stat and Aura-Tek FDP tests. So far, these markers have achieved only an arguable and marginal role in daily clinical practice, challenging the role of cytology and helping decide the type of cystoscopy. A more substantial role awaits a test with higher and more consistent sensitivity and specificity, together with the capability to provide independent diagnostic and/or prognostic information. In this part of the review we examine the literature view of the above-mentioned tests, as well as other new and some older tests such as blood group-related antigens, Lewis antigen, cytokeratins and others.

Bleeding following retropubic prostatectomy: simple digital rectal pressure could be lifesaving.

PURPOSE: A technique to control venous bleeding after retropubic prostatectomy is described. MATERIALS AND METHODS: A man underwent retropubic prostatectomy for an enlarged benign prostate following which hemorrhage occurred. RESULTS: After failure of other more traditional methods of hemostasis, the bleeding was stopped by direct anterior digital rectal pressure. CONCLUSIONS: Simple digital rectal pressure is a safe, effective and logical method of controlling venous bleeding from the dorsal venous or other plexus between the rectum and symphysis pubis.

Statistical review and analysis of the relationship between serum prostate specific antigen and age.

PURPOSE: We investigated the possibility that the variations in the reported correlation coefficient (r) between age and serum prostate specific antigen (PSA) is simply a reflection of the differences in the age mix of the population studied, that is the younger the population the greater the correlation and vice versa. Also, we quantified the value of r for different age groups to evaluate finally the plausibility of its practical application on sound statistical basis. MATERIALS AND METHODS: Bivariate and multivariate regression analyses were done of all identified reports in the literature that specified the exact value of r and the percentage distribution of the population studied in 10-year age groups. RESULTS: The correlation coefficient between r and the percentage of the population in different age groups was statistically significant, confirming the hypothesis that the greater the percentage of younger population in the study, the greater the value of r and vice versa. The correlation between age and PSA did change with age. It was significantly high in the fifth to sixth decades of life (range 0.5 to 0.7) [corrected] and markedly decreased in decade 7 to become low and insignificant in decade 8. CONCLUSIONS: The value of the correlation between age and PSA is sufficiently high to allow for its practical application up to age 60 years. Beyond that age the correlation is so low that its practical application becomes statistically flawed. This finding seems to match the practical experience when applying age-specific PSA ranges in the diagnosis of early prostate cancer.

The performance characteristics of the bladder tumour antigen test.

OBJECTIVE: To evaluate the specificity and sensitivity of the Bard bladder tumour antigen (BTA) (Bard Inc, Covington, USA) test. PATIENTS AND METHODS: The performance of the BTA test was assessed prospectively in 98 patients (30 women and 68 men, mean age 64 years, median 67, SD 14.8) undergoing cystoscopy for various indications. The urine of the patients was assessed using the BTA test, cytology, culture and a dipstick test for haematuria, and the results compared with those from cystoscopy as the 'standard'. RESULTS: The overall specificity for the BTA test was 79% and the sensitivity 37%. The sensitivity was higher than for urine cytology (33%) but less than for the dipstick test (59%). The specificity was less than for cytology (100%) but higher than for the dipstick test (66%). CONCLUSION: The BTA test is a rapid, non-invasive qualitative test identifying degradation products of the basement membrane of the transitional cell epithelium. It represents an advance in the search for a 'tumour marker' for carcinoma of the bladder. The specificity is acceptable but the sensitivity relatively low, which limits its value in everyday practice. Further research and development are needed to improve sensitivity.

Factors influencing blood loss in transurethral resection of the prostate (TURP): auditing TURP.

OBJECTIVES: To assess the blood loss accompanying TURP and investigate its association with the resected weight of prostatic tissue, type of anaesthesia, type of presentation, histology, different surgeons and their differing techniques, and thus to reduce the morbidity associated with blood loss and transfusion. PATIENTS AND METHODS: All prostatectomies carried out in a district general hospital were audited prospectively, recording the pre- and post-operative haemoglobin concentration (Hb), blood transfusions and the variables listed above. The audit was repeated a year later. RESULTS: The peri-operative blood loss, as assessed by various indicators, was equivalent to a decrease in Hb of 10-15 g/L (8-11%). The weight of the resected prostatic tissue was the most important measurable factor in determining blood loss. Regional anaesthesia was associated with less blood loss than general anaesthesia. The added use of a suprapubic catheter for irrigation appeared to have a marginal advantage in large resections. The type of presentation, elective or otherwise, and the histological nature of the prostate did not influence blood loss. Smaller transfusions were probably avoidable in patients having smaller resections and a normal pre-operative Hb. On re-auditing, the overall transfusion rate was reduced from 10.8% to 8.2% and from 4.4% to 1% in patients having resections of < 30 g. CONCLUSION: Blood transfusion can be reduced and rationalized. Patients with a normal pre-operative Hb and undergoing resections of < 30 g do not usually require transfusion. Regional anaesthesia is associated with less blood loss but its advantage is overshadowed in practice by the weight of the resected tissue. An audit of this type is repeatable and is useful in raising awareness, objectively assessing differences and advocating and assessing any changes made.

Length of postoperative hospital stay after transurethral resection of the prostate.

The aim of the study is to explore the value of audit in investigating and reducing the length of stay (LOS) of patients after transurethral resection of the prostate (TURP). All TURPs in a district general hospital (DGH) were audited over 30 weeks. Particular attention was paid to patients whose LOS was longer than the average for the group (mean: 6.4 nights; median: 5 nights). Older age of the patient, larger resections and late removal of suprapubic catheters were statistically significant in prolonging LOS (P < 0.001). General anaesthesia was associated with longer stay than regional anaesthesia, but the difference was not statistically significant. Among patients whose LOS exceeded the average of 6 nights, social circumstances and detrusor underactivity were the most important causes of late discharge, accounting for 44% (28/63) of these cases. Where factors were avoidable, changes were implemented. Increased use of regional anaesthesia was encouraged. Catheters were removed earlier, and discharges, whenever possible, were pre-planned. A re-audit was carried out 1 year after the original audit and a significant decrease in LOS was found (mean: 5.2 nights; median: 4 nights; P < 0.01). Audit can increase awareness of prolonged hospital stay and highlight areas for change. Re-audit can confirm the effectiveness of these changes.

Prostate-specific antigen and age. Is there a correlation? And why does it seem to vary?

OBJECTIVES: To determine whether there is a significant correlation between age and prostate-specific antigen (PSA) and to explain the wide literature variations in its value. METHODS: Two different groups were studied; the first (n = 403) consisted of patients undergoing prostatectomies for symptomatic benign prostatic hypertrophy (BPH) and the second (n = 192) of patients with no evidence of prostate cancer who required no treatment. RESULTS: The correlation coefficient found in the surgical group was low (0.09) and was statistically insignificant while in the second group it was much higher (0.36) and had a high statistical significance (p < 0.001). This reflected the age difference between the two groups rather than the difference in clinical characteristics as proved by the gradual decrease in the value of the coefficient by the gradual exclusion of the younger age groups. The correlation became statistically insignificant for those older than 60 years. CONCLUSIONS: It is concluded that the correlation between age and PSA is a variable one showing a gradual decline in its coefficient with the gradual increase in the age of the population studied. This implies a relatively orderly rise in PSA with age up to a limit of 60 years. Beyond this age, the relationship between age and PSA becomes disorderly. This pattern of relationship can easily be explained by the known rate of growth of BPH and would explain the literature variations.