Diagnosis of prostate cancer: optimal number of prostate biopsies related to serum prostate-specific antigen and findings on digital rectal examination.

The optimal number of core biopsies of the prostate that are needed for the detection of prostate cancer is unknown. A retrospective review of protocols and charts concerning 1149 transrectal ultrasound examinations with biopsy performed in 1013 patients was undertaken. Cancer detection rate was correlated to findings on digital rectal examination (DRE), serum levels of prostate-specific antigen (PSA) and number of biopsies taken. The cancer detection rate was significantly higher in patients who had five or more cores taken compared to those who had four or less (49% versus 35%, p < 0.05) in patients with serum PSA less than 10 ng/ml and a DRE suspicious of malignancy. The same trend was seen in patients with normal DRE and PSA less than 10 ng/ml (14% versus 8%, p = 0.057), while the detection rate for prostate cancer was unaffected by the number of cores taken if serum PSA was above 10 ng/ml.

Transrectal ultrasound examination of the prostate: complications and acceptance by patients.

Transrectal ultrasound scan (TRUS) of the prostate was performed on 511 patients, 391 of whom also underwent between 1 and 5 transrectal 1.2 mm core biopsies. The infection rate in the whole group was 4.1%; 32% of the patients were given antibiotic prophylaxis with norfloxacin 400 mg twice daily for 1 week and in this group the infection rate was 0.8%. In the remaining patients, who received 400 mg norfloxacin at the time of biopsy and another 400 mg the same evening, the infection rate was 5.6%. The only risk factor identified for post-biopsy infection was steroid medication. Only minor discomfort (or none at all) was reported by 95% of patients during the examination procedure. If TRUS was combined with core biopsy 92% reported either minor or no discomfort. Of 78 patients who experienced both finger-guided fine needle aspiration biopsy and TRUS-guided core biopsy 82% preferred the latter procedure. TRUS and core biopsy proved acceptable to most patients. Antibiotic treatment with 2 tablets of norfloxacin failed to prevent infection.

Quality of life after radical retropubic prostatectomy for carcinoma of the prostate.

131 patients treated by radical prostatectomy for localized prostatic cancer were studied with regard to quality of life. The patient's perception of his state of health before operation and 3, 6, 12 and 18 months later was assessed by questionnaires on 272 occasions. In the short term the patients complained of anxiety, voiding disorders, and loss of potency. In the long term only distress due to lack of erection persisted, but the overall well-being after 18 months was nevertheless better than before treatment.

Radical retropubic prostatectomy for localised prostatic carcinoma: a clinical and pathological study of 201 cases.

To examine the role of radical retropubic prostatectomy in clinically localised prostatic cancer we reviewed a series of 201 patients all of whom had undergone bilateral pelvic lymphadenectomy. Frozen section showed metastatic pelvic lymph nodes in 13 cases and 6 cases were too locally advanced for operation; prostatectomy was done for the remaining 182. The pathological staging was based on examination of sections of the whole organ. In 109 (60%) the carcinoma was confined to the prostate gland or to the specimen, in 46 (25%) there was carcinomatous growth in the surgical margin, and in 27 (15%) there was invasion of the seminal vesicles. The Gleason score was significantly higher in cases with involvement of the surgical margin or seminal vesicles. There was one operative death (of pulmonary embolism), and the postoperative cardiovascular morbidity was 7%. The incidence of wound infection was 6%, and there were two rectal injuries and three symptomatic lymphoceles. A total of 135/170 evaluable patients (79%) were completely continent postoperatively, and only two developed severe incontinence. Erectile potency was preserved in 24 of 126 (19%). We conclude that radical retropubic prostatectomy is safe and that the complication rate is acceptable. The completeness of the tumour excision seems to be associated with the pathological grade of the tumour.

Repeated screening for carcinoma of the prostate by digital rectal examination in a randomly selected population.

Of 9,026 males aged 50-69 years, 1,494 were randomly selected and invited to participate in a programme including two screenings for carcinoma of the prostate by digital rectal examination performed in 1987 and 1990. The remaining 7,532 served as a control group. Of the selected persons, 78% accepted the invitation to the first screening round and 70% to the second one. Carcinoma of the prostate was suspected in 45 of 1,163 men examined at the first screening round and in 42 of 953 at the second round. Carcinoma was confirmed by fine-needle aspiration biopsy in 13 cases from the first and in 7 from the second round. In the study group, 17.4 carcinomas were diagnosed per 1,000 men and in the control group 8.6 per 1,000 men. The screening cost was 1,640 pounds per detected cancer and 2,343 pounds per detected and potentially cured cancer. Screening for carcinoma of the prostate by digital rectal examination can be organised with a high population acceptance, and at a reasonable cost. The impact of screening on mortality in prostatic cancer remains uncertain.

Screening for carcinoma of the prostate in a randomly selected population using duplicate digital rectal examination.

Of 9,026 males, aged 50-69 years, 1,494 were randomly selected and invited to participate in a screening programme for carcinoma of the prostate. Of these 1,163 (78%) accepted. Rectal examination was performed independently by a general practitioner (GP) and by a urologist at the GP's surgery. Carcinoma of the prostate was suspected by one or both physicians in 45 cases, and subsequently confirmed by cytological investigation in 13 cases. Ten patients underwent radical prostatectomy, one received radiation treatment, one case was too advanced for curative treatment, and one was scheduled for subsequent reassessment. Screening, as a means of early diagnosis of carcinoma of the prostate by either a urologist or a GP, using digital rectal examination, thus appears to be a cost-effective procedure, though the question still remains whether this will lead to prolongation of survival or not.

Diagnosis and localization of prostate carcinoma by fine-needle aspiration cytology and correlation with histologic whole-organ sections after radical prostatectomy.

Twenty-nine patients with clinical stage T1-2, NO, MO prostate carcinoma were treated by retropubic radical prostatectomy. Diagnosis was made by fine-needle aspiration biopsy from six to eight separate sectors of the prostate. At the time of biopsy, diagrams of the palpated organ were drawn, depicting the location of the lesion and the site of each biopsy. Without the examiners' knowledge of cytologic data, extirpated prostate glands were examined with whole organ histologic sections, and carcinomas were scored according to the method of Gleason. The location and extent of all typical and malignant foci were mapped on a standard diagram. The results of preoperative cytologic examination were compared with postoperative histopathologic findings, showing a tendency toward underestimation of both the extent and degree of differentiation of the carcinomas during cytologic examination. In no case were these parameters overestimated during cytologic examination. The Gleason score correlated well with the presence of capsular and seminal vesicle invasion.

Costs and benefits of early detection of prostatic cancer.

During recent years prostatic cancer has emerged as an increasing health problem in many countries. However, there is reason to believe it can be cured if detected at an early stage while still confined to the prostate. An effective screening programme could thus alter the natural history of the disease and reduce the overall mortality. But the benefit of such a programme is still under debate. A pilot programme using rectal-digital examination to investigate organisational, social and economical aspects was carried out. This information was then used to estimate the consequences of routine prostatic screening in the Swedish health service with aid of a decision analysis model. The study shows that prostatic cancer screening by rectal-digital examination can be organized as an integral part of primary health care, with high acceptance by the public. The total economic burden of screening on the health care sector will be high. The total expected health care cost in Sweden for all diagnosed prostatic cancers during the next 2 years, without screening, was estimated to be 53 million USD (in 1989 prices). 1048 patients were expected to be offered some potentially curative therapy. With rectal-digital examination the total cost during the next 2 years would be 131 million USD and 6522 patients would be given treatment. Alternatively, with transurethral ultrasound examination, the total cost would be 174 million USD and 10275 patients would receive potentially curative therapy. The ultimate health benefits of potentially curative treatment remain uncertain. Until we have scientific evidence of the cost-effectiveness of this method the model presented for analysing the consequences of different strategies could well prove helpful in policymaking for this complex problem.

Screening for carcinoma of the prostate by digital rectal examination in a randomly selected population.

OBJECTIVE: To study the acceptability, costs, psychosocial consequences, and organisation of screening for carcinoma of the prostate. DESIGN: A randomly selected population was personally invited for digital rectal examination by a urologist and a general practitioner. Further examinations were performed if induration was felt. Each man completed a questionnaire on his response to the examination. SETTING: General practices in the area of Norrköping. PATIENTS: 1494 Men aged 50-69 randomly selected from a population of 9026. MAIN OUTCOME MEASURE: Prostates having a firm nodular consistency. RESULTS: Carcinoma of the prostate was suspected in 45 of 1163 patients examined; in 10 by the general practitioners, in 10 by the urologists, and in 25 by both. Forty four men had a fine needle aspiration biopsy, and carcinomas were found in 13 cases. Of these, one had been suspected by the general practitioner, four by urologists, and eight by both. The cost for each man was 11.60 pounds, and the cost for each case of carcinoma detected and treated by potentially curative methods was 2477 pounds. Of the 13 men with carcinoma, 10 underwent radical prostatectomy and one radiotherapy. One man had advanced disease and was given endocrine treatment, another was not treated. Only 193 men felt distress during the initial examination. Of the 44 men who had an aspiration biopsy, 25 experienced anxiety. CONCLUSIONS: Screening for carcinoma of the prostate by a urologist or a general practitioner using digital rectal examination is a cost effective method of early diagnosis. Whether such screening leads to prolonged survival, however, remains doubtful.

Experience of screening for carcinoma-in-situ of the testis among young men with surgically corrected maldescended testes.

One hundred and twelve young men with maldescended testes which had been surgically corrected were examined for premalignant/malignant changes in the testes. Bilateral testicular biopsies were made in ninety-four patients. Three had carcinoma-in-situ of the testis in the biopsy. Invasive tumour of seminomatous type was found in two of these testes after orchidectomy had been performed. No correlation was found with testicular localization pre- or postoperatively, with testicular volume or with tumour markers.

Crossed ectopia of a solitary kidney.

Crossed ectopia of a solitary kidney, a rare congenital anomaly, was accidentally disclosed in connection with a gynaecological emergency. The patient had no symptoms from the urinary tract. The condition is discussed and the importance of its recognition is pointed out.