Extensive emphysematous pyelonephritis.

We report an unusually severe case of emphysematous pyelonephritis with very extensive kidney necrosis that led to unilateral nephrectomy. We discuss the diagnosis and treatment options in this very rare complication of pyelonephritis almost exclusively encoutered in diabetic patients.

Screening for prostate cancer. Comparison of transrectal ultrasound, prostate specific antigen and rectal examination.

In seeking to define the relative value of transrectal ultrasound (TRUS), prostate specific antigen (PSA) and digital rectal examination (DRE) in the diagnosis of prostatic cancer, 863 patients were studied and the findings compared. DRE detected malignancy in 0.3% of the population of asymptomatic "normal" men undergoing routine health screening, and in 1.6% of patients who consulted their General Practitioner for one reason or another. In patients who attended our out-patient department with a variety of urological symptoms (not necessarily prostatic), TRUS suggested malignancy in 2% of those glands which were pronounced normal on DRE. Significantly elevated PSA detected malignancy in 0.3% of the patients undergoing routine health screening. (Although this figure equals the pick-up rate by DRE in this group, they were not necessarily the same patients). When these 3 investigations are summated, the pick-up rate is twice as high as when a single parameter is used.

[Circulating prostate cancer specific antigens in benign hypertrophy and localized cancer of the prostate]. / L'antigène prostatique spécifique circulant dans l'hypertrophie bénigne et le cancer localisé de la prostate.

In benign hypertrophy of the prostate (88 patients) there is a good correlation between the circulating specific prostate antigen (SPA) and the size of the prostate or of the adenoma. This correlation disappears with an adenocarcinoma where tumor volume increases (46 patients). Used as a screening test for cancer, serum levels of SPA, with a threshold value of 2.5 ng/ml, has a 91 per cent sensitivity and a 37 per cent specificity. At 15 ng/ml the sensitivity is 50 per cent and the specificity is 85 per cent. Alone, the SPA level is a poor diagnostic tool: using the low threshold (2.5 ng/ml) leads to needle biopsy in most all benign hypertrophies; with the high threshold (15-23 ng/ml), 50 per cent of the localized cancers go undetected. However, for a level greater than 15 ng/ml, SPA is an argument strongly suggesting prostate adenocarcinoma. The capacity of benign hypertrophy of the prostate to "secrete" SPA is 5 times greater than the normal peripheral prostate; the capacity of cancer is 20 times greater than that of the adenoma. Individual variability in serum levels of SPA, expressed per cm3 of prostate tissue is too great to give a precise interpretation as a function of volume.

[Circulating prostatic-specific antigen in benign hypertrophy and localized prostate cancer: can PSA be considered a screening examination for localized cancer?]. / Le PSA circulant dans l'hypertrophie bénigne et le cancer localisé de la prostate: le PSA peut-il être considéré comme un examen de dépistage du cancer localisé?

Prostate-specific antigen (PSA) is increasingly used in the diagnosis of prostatic pathology. Its usefulness in the early diagnosis of prostatic cancer is controversial. The aim of the study is to evaluate the sensitivity and specificity of PSA in a population with prostate diseases. Moreover, we wanted to know if the measure of the prostate volume may increase the sensitivity of the test. In benign prostatic hypertrophy (88 patients), a good correlation exists between circulating PSA and the prostatic volume or the volume of the adenoma. This correlation disappears in the presence of an adenocarcinoma at the profit of the tumor volume (46 patients). Used as a means of screening for cancer, the serum level of PSA with a threshold value of 2.5 ng/ml has a sensitivity of 91% and a specificity of 32%. The sensitivity is 50% and the specificity is 85% at a level of 15 ng/ml. Taken alone, the level of PSA is inadequate for diagnosis: If the lower level is chosen (2.5 ng/ml), the majority of benign prostatic hypertrophies will be the object of a biopsy. If the higher level is chosen (15-23 ng/ml), 50% of localized cancers of the prostate will escape detection. Nevertheless, a level of PSA < 15 ng/ml is an argument for a strong suspicion in favor of an adenocarcinoma of the prostate. The capacity of BPH to "secrete" serum PSA is five times greater than that of the normal peripheral prostate, and the capacity of cancer is 20 times greater than that of an adenoma. The individual variability of serum PSA per cubic centimeter of prostatic tissue is too great to allow a precise interpretation as a function of volume.

The significance of the prostatic hypoechoic area: results in 226 ultrasonically guided prostatic biopsies.

A total of 666 patients with symptoms of urinary outflow obstruction underwent assessment of the patients 64 had a palpable abnormality suggestive of cancer (stages T1 to T4, or B to C). In the remainder the prostate was either palpably normal, firm or enlarged by benign prostatic hypertrophy. All 64 patients with a palpable abnormality and 162 of 602 with normal rectal examination findings had a hypoechoic area on transrectal ultrasound. Biopsy of the ultrasonic abnormality was done in 148 men by the transperineal route with linear array ultrasound guidance and in 78 by the transrectal route with a mechanical sector scanner in the sagittal plane. Of the 64 patients with a nodular prostate 34 (53%) had cancer (31% of those with stages T1 and 2, 83% with stage T3 and 100% with stage T4 disease). In 14% of the patients with stages T1 and T2 cancer the biopsy showed prostatic intraepithelial neoplasia grade 3. Of the 162 patients with a palpably normal prostate who underwent ultrasound-guided biopsy 11 (6.7%) had cancer and 6 (3.7%) had grade 3 prostatic intraepithelial neoplasia detected in the biopsy material. Patients with stages T1 to T2 cancer and those with ultrasound-diagnosed impalpable cancer were not significantly different with respect to patient age (67 versus 70 years), cancer size (3.0 +/- 1.6 versus 3.9 +/- 2.5 cm.2) or Gleason score (5.4 +/- 1.2 versus 6.5 +/- 0.9). The results demonstrate that ultrasound guidance improves the yield of prostate needle biopsy. Furthermore, it is suggested that prostate cancer found by ultrasound alone is not different from early palpable disease and should be treated in the same manner.

[The significance of the use of fibrin glue in complete cystectomy with urinary diversion]. / Intérêt de l'utilisation de la colle de fibrine dans la cystectomie totale avec dérivation urinaire.

Two groups of 15 patients were submitted to radical cystoprostatectomy with urinary diversion. Was used in one group. Fibrin glue appears to be a valuable progress to improve the immediate follow-up of these patients, in terms of morbidity and the duration of parenteral assistance.

[Early diagnosis of cancer of the prostate. Hypothetic role of transrectal echography]. / Diagnostic précoce du cancer de la prostate. Place hypothétique de l'échographie transrectale.

In order to clarify the value of transrectal ultrasonic examination of the prostate in the diagnosis of prostatic cancer at an early stage, 666 patients were screened in one year; 602 of them (TO) had a normal, firm or hypertrophic but non-nodular prostate at digital rectal palpation, 41 had a T1-T2 prostate and 23 a T3-T4 prostate. Among the 602 TO prostates, 162 showed a hypoechoic peripheral area which was biopsied, revealing an infiltrating carcinoma in 11 cases. The ability of transrectal ultrasound alone to detect TO cancer was estimated at 1.8 per cent (11/602). The positive predictive value of a hypoechoic image of the prostate was estimated at 7 per cent (11/162), which is much lower than the figures reported in the literature. Transrectal ultrasound can be considered an acceptable method for detecting TO tumours of the prostate with a yield comparable to that of digital rectal palpation in the T1-T2 tumours. The low performance (1.8 per cent) of transrectal ultrasound in detecting cancer at an early stage rules out any mass screening programme of the male population over 50 years of age. However, 45 per cent of localized tumours in this series were detected by transrectal ultrasound.