Local control of prostate cancer by transrectal HIFU-therapy.

Transrectal high intensity focused ultrasound (HIFU) as a minimal invasive treatment approach of localized prostate cancer was evaluated concerning its efficacy and security. Post-operative monitoring included PSA-levels and histological results of control random biopsies. Seventy-three HIFU sessions were performed on 62 patients during the period from November 1997 to April 2000. Patients were classified in 4 indication groups: 1) localized prostate cancer, T1-T2, initial PSA < 15 ng/ml, Gleason score < 7, volume < 30 cc, no more than 4 of 6 random biopsies affected by cancer, not suitable for radical prostatectomy; 2) localized prostate cancer, T1-T3, no PSA or Gleason score limitation; 3) local recurrence after first line therapy (RPE, radiation, hormonal ablation); 4) for local debulking. Mean plus or minus standard deviation for patient age was 67.5 +/- 7.48 years, for PSA was 7.64 +/- 5.26 ng/ml and for prostate volume was 21.3 +/- 7.9 cc. Median follow up was 15 months (range 5-29) and included PSA development, control sextant biopsies and transrectal color coded duplex sonography (TCCDS) at 1, 3, 6, 12 and 24 months. At least 1 control biopsy result was available in 48 patients. We evaluated the therapy in 3 categories: 1) group 1 (complete response) included 33/48 patients (68.7%) with no residual cancer and PSA < 4 ng/ml; 2) group 2 (biochemical control) 8/48 patients (16.7%) with small residual cancer and PSA < 4 ng/ml; 3) group 3 (failure) 7/48 patients (14.6%) with residual cancer and PSA > 4 ng/ml (4 of them received hormone therapy). As major complications 2 urethrorectal fistulas occurred, both in post-radiation patients, 3 stress-incontinences II-III after TUR post HIFU. In 20 patients (32.3%) transurethral manoeuvres were necessary to remove obstructive necrotic tissue or because of bladderneck or urethral strictures. 11 of these patients were among the first 20 treated patients. Regarding the individual learning curve about technique, indication and the technical developments HIFU treatment can currently be considered as a valid alternative treatment strategy for patients with localized prostate cancer, who are not suitable for radical surgery. HIFU treatment can be repeated depending on biopsy result and PSA development. Local control of the localized prostate cancer was observed in group 1 and 2 (85%).

Correlation of persistent stress urinary incontinence with quality of life after suspension procedures: is continence the only decisive postoperative criterion of success?

OBJECTIVES: To determine objective continence rates and to include in the evaluation subjective assessment of continence and quality of life by the affected patients and correlate these with the objective continence rates in a retrospective study. METHODS: One hundred thirty-three female patients in our clinic underwent suspension procedures for stress urinary incontinence, 68 undergoing a Burch colposuspension and 65 a Raz bladder neck suspension. The continence rate was evaluated by questionnaire and compared with patients' postoperative self-assessment of continence and pre- and postoperative quality of life assessments. RESULTS: For the 105 women returning evaluable questionnaires (57 Burch and 48 Raz procedure), the continence rate was 69.5% (75.4% in the Burch group, 60.4% in the Raz group). Mild incontinence requiring 1 to 2 sanitary pads daily was found in 19.3% of the Burch group and 31.3% of the Raz group. Moderate incontinence requiring 3 to 5 pads daily was found in 5.3% of the Burch and 8.3% of the Raz group. No patients had severe incontinence (more than 5 pads daily). Both groups showed statistically significant improvement in postoperative quality of life. Despite persistent incontinence, the satisfaction rate was comparable to that of continent patients. CONCLUSIONS: The results show that in addition to objective parameters, subjective assessment of quality of life is a factor that should be included in the postoperative evaluation of surgical results.

Clinical results of the transurethreal resection and evaluation of superficial bladder carcinomas by means of fluorescence diagnosis after intravesical instillation of 5-aminolevulinic acid.

BACKGROUND AND OBJECTIVE: The high recurrence rate of superficial bladder carcinomas requires new approaches in diagnosis and therapy. Particularly, an improvement in detection, resulting in better resection of flat lesions, which are poorly or not detectable under white light, is necessary. The effectiveness of fluorescence diagnosis for detection and transurethral resection of bladder carcinomas was investigated in a prospective study. MATERIALS AND METHODS: From 120 patients, 347 biopsies were taken or tumors resected with the aid of fluorescence from 5-aminolevulinic acid. Urothelial carcinomas and dysplasias were detected in 124 cases. RESULTS: Of the lesions, 119 were fluorescence positive (N = 74 pTaG1/2; N = 9 pT1G1/2; N = 11 pT1G3; N = 7 carcinoma in situ; N = 6 p > T1; N = 12 dysplasia II), and 5 were falsely negative (N = 3 pTaG1/2; N = 1 pT1G1/2; N = 1 dysplasia II). The sensitivity of the fluorescence diagnosis (96.0%) was significantly higher than the 67.5% sensitivity of white-light cystoscopy (P < 0.0001). Taking the data for primary or recurrent tumor resection and secondary resection separately, the sensitivity was 100% and 80%, respectively, and was significantly higher than that of white-light cystoscopy, which was 80.8% and 20 %, respectively (P < 0.0001 and P < 0.0008). The lower sensitivity of fluorescence diagnosis in secondary transurethral resection is attributed to the higher rate of false-negative findings in areas of former resection. CONCLUSIONS: The high rate of false-positive findings limits the correct interpretation of fluorescence findings. In spite of this, fluorescence diagnosis is superior to white-light cystoscopy in every case. By means of better detection of urothelial neoplasias and dysplasias, as well as more thorough and extensive resection under fluorescence control, it should be possible to reduce the recurrence rate of superficial bladder carcinomas.

5-aminolevulinic acid-induced fluorescence endoscopy applied at secondary transurethral resection after conventional resection of primary superficial bladder tumors.

OBJECTIVES: A prospective investigation was carried out to evaluate the use of 5-aminolevulinic acid (5-ALA)-induced fluorescence diagnosis with secondary transurethral resection (TUR). METHODS: Fifty patients underwent secondary TUR of the former resection area 6 weeks after conventional TUR for superficial bladder carcinoma. 5-ALA-induced fluorescence diagnosis was used in addition to standard white light endoscopy. All former resection areas were biopsied regardless of fluorescence findings. In addition, specific red fluorescent areas were resected, as were suspicious areas seen at white light endoscopy. RESULTS: One hundred thirty areas or tumors were resected. The sensitivity of fluorescence cystoscopy was 77.8% (95% confidence interval 52.4% to 93.6%). Residual tumors were found in the area of the former resection in 7 (14%) of 50 patients; 4 of these 7 were fluorescence negative and 3 were fluorescence positive. In an additional 7 patients (14%), exclusively fluorescing tumors not visible under white light could be detected outside the areas of former resection (n = 5, Stage pTaG1/2; n = 1, Stage pT1G1/2; n = 1, carcinoma in situ). CONCLUSIONS: Despite high sensitivity, fluorescence diagnosis at this early stage of control does not allow us to evaluate sufficiently the granulation tissue of necrotic areas after TUR without biopsy. The main advantage of the 5-ALA-induced fluorescence endoscopy is in the evaluation of untreated urothelium because of the easier detection of tumors not visible by conventional endoscopy.

Microlenses as Amplification for CCD-Based Detection Devices for Screening Applications in Biology, Biochemistry, and Chemistry.

We describe the use of microlenses as amplification for CCD-based detection devices. The possible amplification of a signal in areaction chamber of a nanoplate is estimated with a first-order approximation. This value was proved with a commercially available microlens and with a specially constructed microlens array made of glass hemispheres. Possible applications of this approach to amplification are given.

Follow-up of moderately elevated serum CEA levels in "healthy patients".

In a retrospective analysis of 254 patients with a moderately elevated serum CEA level (3.6 to 10.0 ng/ml) a satisfactory explanation for the increased CEA level could not be identified in 42 patients despite intensive diagnostic procedures. The follow-up of these patients showed a decrease of CEA level in 28 patients (80%), returning to normal range below 3.5 ng/ml in 20 patients (57%). There was an increase of CEA level in 5 (14.3%) and no change in two patients (5.7%). Except one patient who died of an unknown cause, none of the other patients developed malignancy in a period up to 34 months. We conclude that a single elevated serum CEA level does not justify further diagnostic procedures if clinical signs of a disease are absent. Patients with increasing CEA levels should be checked more intensively, because in some cases a previously undetectable malignant disease may become evident.