Local recurrence after radical prostatectomy: correlation of US features with prostatic fossa biopsy findings.

PURPOSE: To evaluate the diagnostic accuracy of transrectal ultrasonography (US) in the detection of local recurrence following radical prostatectomy. MATERIALS AND METHODS: Ninety-nine patients with biochemical recurrence after radical prostatectomy were evaluated at transrectal US and prostatic fossa biopsy. Location of suspected recurrence at transrectal US and clinical features, such as prostate-specific antigen levels and digital rectal examination findings, were correlated with biopsy results. RESULTS: Forty-one (41%) of 99 cases of local recurrence were detected. The percentage of sites of lesions identified at transrectal US and corresponding positive biopsy rates were as follows: the urethrovesical anastomotic area, 56% and 61%; bladder neck, 26% and 54%; retrovesical space, 4% and 100%; and more than one site, 14% and 71%. By comparing transrectal US and digital rectal examination, the sensitivities were 76% and 44% (P =.007), while specificities were 67% and 91% (P =.004), respectively. An increased positive biopsy rate with increasing prostate-specific antigen levels was noted (P =.04). CONCLUSION: Transrectal US is more sensitive but less specific than digital rectal examination in the detection of local recurrence. Biopsy findings in more than half of the suspected lesions at the urethrovesical anastomotic area and bladder neck were positive. Lesions in the retrovesical space, although less frequently encountered, had a high likelihood of representing cancer recurrence.

Characteristics of normal prostate vascular anatomy as displayed by power Doppler.

BACKGROUND: To define the vascular anatomy of the normal prostate as depicted by power Doppler and to provide baseline data for evaluation of this modality in the diagnosis and management of prostatic disease. METHODS: The vascular anatomy of 40 subjects was studied. Power Doppler images were correlated with corresponding gray-scale images. Doppler spectral waveform measurements were obtained for the vessels identified. RESULTS: Separate branches of the capsular vessels were visualized clearly, distributed radially in the peripheral and central zones and converging toward the center of the gland. Urethral vessels were visualized in the transition zone coursing from bladder neck to verumontanum. The neurovascular bundles were identified posterolaterally along the length of the gland. No significant difference between the resistive indexes of the urethral and capsular vessels was identified (P = 0.595), although there was a significant difference between the resistive index of the neurovascular bundles and that the prostatic vessels (P < 0.001). CONCLUSIONS: The vascular anatomy of the normal prostate as displayed by power Doppler demonstrates a reproducible and symmetric flow pattern. Power Doppler is highly sensitive in depicting blood flow, the number, course, and continuity of vessels more readily than other imaging modalities, such as color Doppler. These data should allow comparison of the vascular anatomy of the normal prostate with that of the prostate with diseases such as prostate cancer and benign prostatic hyperplasia.

Prediction of response to salvage radiation therapy in patients with prostate cancer recurrence after radical prostatectomy.

PURPOSE: To identify factors predictive of local recurrence as defined by a complete response to salvage radiation therapy in patients whose disease recurs after radical prostatectomy. PATIENTS AND METHODS: Ninety-five patients with recurrence after radical prostatectomy who were evaluated by prostatic fossa biopsies, and a subset of 49 of these patients treated with radiation for control of presumed or biopsy-proven local recurrence, were studied. RESULTS: Biopsies were positive in 40 (42%) of the 95 biopsied patients. Multivariate analysis revealed that prebiopsy prostate-specific antigen (PSA) level, postrecurrence PSA doubling time, and positive digital rectal examination (DRE) of the prostatic fossa were all statistically significant predictors of a positive biopsy. For the 49 patients subsequently treated with salvage radiation therapy, the overall actuarial 3- and 5-year PSA relapse-free probabilities were 43% and 24%, respectively. Univariate analysis showed no differences in the PSA relapse-free probabilities associated with any pathologic features of the radical prostatectomy specimen, biopsy confirmation of local recurrence, or DRE of the prostatic fossa. In multivariate analysis, controlling for all other variables, preradiation PSA and postrecurrence PSA doubling time measured before radiation were the only statistically significant predictors of outcome. CONCLUSION: DRE of the prostatic fossa, prebiopsy PSA, and postrecurrence PSA doubling time predict which patients will have biopsy-proven local recurrence. However, response to salvage radiation therapy is associated with postrecurrence PSA doubling time and with preradiation PSA level only. DRE of the prostatic fossa and biopsy confirmation of local recurrence are not associated with salvage radiation outcome.

Detection of metastatic prostate cancer using a splice variant-specific reverse transcriptase-polymerase chain reaction assay for human glandular kallikrein.

We developed a highly sensitive splice variant-specific reverse transcriptase-PCR (RT-PCR) assay for human glandular kallikrein (hK2) mRNA and tested its ability to detect metastatic disease in men with clinically localized prostate cancer. An RT-PCR assay using primers spanning intron IV and including a significant portion of the 3' untranslated region of the hKLK2 gene, with maximum nonhomology to both hK1 and hK3, was developed. The limit of detection of the assay was five copies of hK2 cDNA and one LNCaP cell in 10(9) lymphoblasts. RT-PCR-hK2 was performed on preoperative peripheral blood specimens from 228 consecutive radical prostatectomy patients as well as 7 metastatic prostate cancer patients and 14 healthy men without prostate cancer. This new RT-PCR-hK2 assay amplifies two distinct fragments. The larger fragment (hK2-U) is approximately 680 bp in length and corresponds to the amplified product of a previously reported splice variant in the splice donor site of intron IV in the hKLK2 gene. The smaller fragment (hK2-L) is approximately 643 bp in length and corresponds to the amplified product of the native hK2 mRNA. Whereas the RT-PCR-hK2-L assay was positive in 71% of our patients with metastatic prostate cancer, 14% of healthy control men also tested positive. By univariate (P = 0.028) and multivariate (P = 0.0269) analysis, which controlled for preoperative PSA, clinical stage, and biopsy Gleason score, RT-PCR-hK2-L status added prognostic information to the prediction of lymph node-positive disease. We have developed a new RT-PCR assay which demonstrates a high sensitivity for detecting hK2 mRNA. Preoperative RT-PCR-hK2-L status helps predict pathological lymph node positivity in patients with clinically localized prostate cancer.

Diagnosis and management of incidental ureterocele during the treatment of clinically localized prostate cancer.

Two instances of simultaneous diagnosis of prostate cancer and ureterocele were recently identified. In one patient an ectopic ureterocele in a duplex system with an obstructed upper pole was unroofed at the time of radical prostatectomy. Surgical excision of the ureterocele wall provided decompression of the obstructed system. In a second patient, bilateral intravesical ureteroceles associated with normal renal units were left untreated. Complications were not associated with the untreated ureteroceles. On rare occasions a ureterocele may be discovered incidentally during the evaluation of patients with prostate cancer. When radical prostatectomy is planned, treatment of the ureteroceles should be determined by the ureterocele's size, anatomic configuration, and location and by the degree of obstruction of the affected renal unit. Surgical excision of the ureterocele at the time of radical prostatectomy may be the best approach for patients requiring treatment.