Antibiotic prophylaxis for transrectal prostate biopsy.

BACKGROUND: Transrectal prostate biopsy (TRPB) is a well established procedure used to obtain tissue for the histological diagnosis of carcinoma of the prostate. Despite the fact that TRPB is generally considered a safe procedure, it may be accompanied by traumatic and infective complications, including asymptomatic bacteriuria (bacteria in the urine), urinary tract infection (UTI), transitory bacteremia (bacteria in the blood), fever episodes, and sepsis (pathogenic microorganisms or their toxins in the blood). Although infective complications after TRPB are well known, there is uncertainty about the necessity and effectiveness of routine prophylactic antibiotics and their adverse effects, as well as a clear lack of standardization. OBJECTIVES: To evaluate the effectiveness and adverse effects of prophylactic antibiotic treatment in TRPB. SEARCH STRATEGY: The search covered the principal electronic databases: MEDLINE, EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL). Experts were consulted and references from the relevant articles were scanned. SELECTION CRITERIA: All randomized, controlled trials (RCTs) of men who underwent TRPB and received prophylactic antibiotics or placebo/no treatment, were selected, and all RCTs looking at one type of antibiotic versus another, including comparable dosages, routes of administration, frequency of administration, and duration of antibiotic treatment. DATA COLLECTION AND ANALYSIS: Two reviewers (ELZ, OACC) independently selected included trials and extracted study data. Any disagreements were resolved by a third party (NRNJ). MAIN RESULTS: Overall, more than 3500 references were considered and 19 original reports with a total of 3599 patients were included.There were 9 trials analysing antibiotics versus placebo/no treatment, with all outcomes significantly favouring antibiotic use (P < 0.05) (I(2) = 0%), including bacteriuria (risk ratio (RR) 0.25 (95% confidence interval (CI) 0.15 to 0.42), bacteremia (RR 0.67, 95% CI 0.49 to 0.92), fever (RR 0.39, 95% CI 0.23 to 0.64), urinary tract infection (RR 0.37, 95% CI 0.22 to 0.62), and hospitalization (RR 0.13, 95% CI 0.03 to 0.55). Several classes of antibiotics were effective prophylactically for TRPB, while the quinolones, with the highest number of studies (5) and patients (1188), were the best analysed. For 'antibiotics versus enema', we analysed four studies with a limited number of patients. The differences between groups for all outcomes were not significant. For 'antibiotic versus antibiotic + enema', only the risk of bacteremia (RR 0.25, 95% CI 0.08 to 0.75) was diminished in the 'antibiotic + enema group'. Seven trials reported the effects of short-course (1 day) versus long-course (3 days) antibiotics. Long course was significantly better than short-course treatment only for bacteriuria (RR 2.09, 95% CI 1.17 to 3.73). For 'single versus multiple dose', there was significantly greater risk of bacteriuria for single-dose treatment (RR 1.98, 95% CI 1.18 to 3.33). Comparing oral versus systemic administration - intramuscular injection (IM), or intravenous (IV) - of antibiotics, there were no significant differences in the groups for bacteriuria, fever, UTI and hospitalization. AUTHORS' CONCLUSIONS: Antibiotic prophylaxis is effective in preventing infectious complications following TRPB. There is no definitive data to confirm that antibiotics for long-course (3 days) are superior to short-course treatments (1 day), or that multiple-dose treatment is superior to single-dose.

Assessment of serum chromogranin-A as prognostic factor in high-risk prostate cancer.

PURPOSE: The presence of neuroendocrine differentiation may play a key role in androgen-independent tumor progression. The prognostic significance of plasma chromogranin-A (CgA) was assessed in a series of consecutive patients with high-risk prostate cancer (PCa). PATIENTS AND METHODS: Twenty-three patients presenting high-risk PCa and 8 healthy individuals, as control group, had their blood samples collected to evaluate CgA, free and total prostate specific antigen, and free and total testosterone in a pilot study. The correlations of serum CgA levels with PSA, testosterone, Gleason score, number of foci of hypercaptation in bone scan, age, and outcomes were evaluated at baseline and after 12 months. RESULTS: Patients with PCa had significantly higher levels of plasma CgA (mean, 8.7; range, 1.9-73) than healthy patients (mean, 3.45; range, 0.6-5.6), P = 0.02. Analyzing only the patients group through correlation of the ranks, it was observed that CgA has low, insignificant correlations with PSA (P = 0.07) and with metastatic extension (P = 0.09). No association was found between the plasma CgA levels and the Gleason score (P = 0.20), age (P = 0.15), or disease progression (P = 0.27). CONCLUSION: The serum levels of CgA were significantly increased in the group with PCa compared with the healthy group. However, there were low correlations between serum CgA and known prognostic factors (such as total and free PSA, age, Gleason score, and bone metastases) or clinical deterioration. Although future studies are needed with larger samples and longer follow-up, the presented data envisage a limited role to serum CgA as high-risk PCa prognostic factor.

The triple clinicopathologic features to seminal vesicle-sparing radical prostatectomy.

BACKGROUND AND PURPOSE: With the widespread early detection programs for prostate cancer, there has been a downward stage migration and a marked decrease in the percentage of men with seminal vesicle invasion (SVI) compared with previous data. We evaluated clinicopathologic findings that are associated with SVI to select patients for potential seminal vesicle-sparing surgery. PATIENTS AND METHODS: We reviewed our radical prostatectomy database from 1997 to 2006 to evaluate the incidence and clinical correlates of SVI. Variables analyzed included serum prostate-specific antigen (PSA) level, clinical stage, percentage of positive cores with cancer, Gleason score on biopsy, age, prostate weight, and urethral and vesical surgical margins. Statistical analysis included univariate and multivariate logistic regressions. RESULTS: Of 267 patients, 32 (12%) had SVI. Preoperative PSA level, biopsy Gleason score, and percentage of positive cores were highly predictive of SVI on multivariate analysis. SVI was present in only 1/98 patients (1.02 %) with biopsy Gleason score ≤6, 0/23 patients (0%) with serum PSA level <4 ng/mL, and only 1 patient with ≤12.8% of positive cores on biopsy. In all cases of distal SVI, there was proximal involvement. CONCLUSION: Serum PSA level, Gleason score, and percentage of positive cores on biopsy are statistically significant predictors of SVI on multivariate analysis. Seminal vesiculectomy does not benefit almost 99% of patients with biopsy Gleason score ≤6, PSA level <4 ng/mL, and with <12% cores with cancer. In cases of seminal vesicle-sparing surgery, frozen section of the proximal portion may be of adjunct usefulness for the triple.