Clinically significant and non significant prostate cancer an ongoing question.

One of the most important problems in urological practice is how to differentiate clinically significant and non significant prostate cancer (Pca) i.e. how to avoid over treatment of tumors with low malignant potential in one hand, and inappropriate less aggressive treatment of significant tumors, on the other hand. At the first place, one should estimate precise local clinical stage and the grade of the disease. Transrectal ultrasound--guided prostate biopsy id the golden standard, but there are few dilemmas concerning prostate biopsy: the number of biopsy cores, inter and intra-observer variations in the grading, the significance of PIN, multifocal character of Pca etc. Our opinion is that sextant or octan biopsy is quite sufficient for the exact detection of clinically insignificant cancers. An additional problem is the discrepancy in grade between biopsy and radical prosatectomy specimen. Second, the treatment should not be the same for every patient and it is guided by the age and general condition of the patient. The aggressive treatment is recommendable for younger patients, younger than 70-72 years, even for tiny area of cancer in one of the biopsy samples. On the other hand, it is an ethical question, should we insist on detection of small cancer foci at older patients, and make them anxious and unhappy in their last years of life.

The urodynamic profile of prostatodynia.

OBJECTIVE: To evaluate urodynamically patients with prostatodynia, and thus define a specific urodynamic pattern that might add to the pathophysiology of the syndrome and possibly aid definitive treatment. PATIENTS AND METHODS: Forty-three patients (mean age 38.1 years, sd 9.25, range 24-59) with symptoms suggestive of chronic prostatitis, e.g. dysuria, frequency of micturition and a burning sensation in the perineum, were classified as having prostatodynia after excluding prostatic infection by standard bacteriological methods. Thereafter, the patients were evaluated urodynamically, including the measurement of free flow-rate, filling (water) cystometry, a pressure/flow study of micturition, with fluoroscopy and electromyography of the external urethral sphincter. RESULTS: Twenty-eight patients (65%) had a low maximum free flow rate (Qmax ), with a mean (sd) of 10.91 (1.26) mL/s. Of the 42 patients who underwent filling cystometry, 26 (62%) had a first sensation of filling, and 28 (67%) a first desire to void, at low volumes (<150 mL and <300 mL, respectively). Of the 25 patients who underwent a pressure/flow study, 16 (64%) had an obstructive pattern of micturition, as defined by a low Qmax of 10.04 (1.38) mL/s and a high intravesical pressure at Qmax of 83.3 (5.3) cmH2O. The site of obstruction was at the level of the bladder neck, as confirmed by fluoroscopy. CONCLUSION: A significant proportion of these patients had a particular urodynamic pattern of functional infravesical obstruction at the level of the bladder neck and sensory disturbances.

Efficacy of escalating doses of intravesical interferon alpha-2b in reducing recurrence rate and progression in superficial transitional cell carcinoma.

OBJECTIVE: To compare the efficacy of three different doses of intravesical interferon alpha-2b (IFN alpha-2b) in reducing recurrence and progression rates in superficial grade II, transitional cell carcinoma (TCC). PATIENTS AND METHODS: Eighty-nine patients with primary or recurrent TCC stage Ta/T1, grade II, were randomly allocated into four groups after transurethral resection (TUR) of the tumour. Group A (20 patients) received no further treatment, serving as the control group; group B (22 patients) received 40 MU of IFN alpha-2b, group C (24 patients) 60 MU and group D (23 patients) 80 MU. The instillations started within 48-72 h after TUR and were performed weekly for 2 months, bimonthly for the next 4 months and thereafter monthly for 6 months. The patients were followed for 36 months. The four groups were compared for the number of recurrences (simple recurrence rate), progression in stage, disease-free interval and recurrence rate per 100 patient-months. RESULTS: During the follow-up, 33 patients had recurrence (13, eight, seven and five in groups A to D, respectively). The simple recurrence rate was 65% for group A, compared with 36% (P = 0.06), 29% (P < 0.05) and 22% (P < 0.01) for groups B, C and D, respectively. The differences in simple recurrence rates between the groups treated with IFN alpha-2b were not statistically significant. Eleven patients experienced progression in stage, with six, there, one and one in groups A to D, respectively. The differences were statistically significant only between groups A and C (P < 0.05) and groups A and D (P < 0.05). The disease-free interval was 15 months for group A, compared with 21.4 (P < 0.05), 26.1 (P < 0.001) and 30 months (P < 0.001) for groups C to D, respectively. The disease-free intervals of the groups treated with IFN alpha-2b were significantly different between all patients in groups B and D (P < 0.01) and only for those with stage T1 between groups C and D (P < 0.01). Finally the recurrence rate per 100 patient-months was 2.91, 1.19, 0.88 and 0.63 for groups A to D, respectively (all P < 0.001). The results were always in favour of the patients treated with the high dose, the only exception being the difference between groups C and D (P = 0.026). No side-effects of the drug were noted, nor was any adverse reaction reported from any patient. CONCLUSION: These results show a significant advantage for adjuvant intravesical IFN alpha-2b treatment over TUR alone for the 36 months of follow up and indicate that IFN alpha-2b can modify the clinical course of superficial TCC at least in the short term. The appropriate dose was apparently 80 MU, for although 40 MU was better than TUR alone, it was less effective than 60 MU and 80 MU; the 80 MU dose was slightly better than 60 MU and thus this regimen is recommended.

Influence of prostate size on terazosin efficacy.

BACKGROUND: While the rationale for the use of alpha1-adrenoreceptor antagonists in the treatment of bladder outlet obstruction is well established, not all patients have either objective or subjective improvement. The aim of this study was to evaluate the influence of prostatic size on the changes of peak flow rate, average flow rate and residual urine in symptomatic BPH patients undergoing terazosin treatment. METHODS: Thirty-five patients with symptomatic BPH received terazosin, 5 mg once a day for 3 weeks after a 2-week dose escalation period. Peak and average flow rates as well as residual urine were assessed before and after treatment. The patients were stratified in 3 groups by prostate size, which was estimated by transabdominal ultrasonography and a digital rectal examination. RESULTS: The baseline characteristics for age, peak flow rate and average flow rate did not vary between the 3 groups, however, the pretreatment volume of residual urine was greater in patients with large prostate adenomas. Terazosin treatment resulted in significant changes in flow rate and residual urine, however, changes in flow rates were not influenced by prostate size, while a marked decrease in residual urine was found in patients with large prostates. CONCLUSION: Patients treated with terazosin obtained similar improvement in peak and average uroflow, independent of the size of the prostate.

Does free to total ratio of prostate-specific antigen alter decision-making on prostatic biopsy?

OBJECTIVES: For patients with prostate specific antigen (PSA) values of 4-10 ng/mL, some urologists perform prostatic biopsies depending upon the findings of digital rectal examination (DRE) and transrectal ultrasonography (TRUS), and others perform biopsies on most of these men regardless of the findings of DRE and TRUS. The purpose of this study was to examine whether the information given by the measurement of the ratio of free to total (F/T) PSA can alter decision-making on prostatic biopsy. METHODS: One hundred and two (102) men with PSA values between 4 and 10 ng/mL, were included in this study. All men were examined with DRE and TRUS; a F/T PSA ratio was also measured, and six prostatic biopsies were taken from each patient. RESULTS: In 102 men who were biopsied, 22 (21.5%) prostatic carcinomas were identified. Among these 22 cancer patients, 13 had abnormal findings in DRE and/or TRUS and would have been biopsied and diagnosed anyway. If we use only the F/T PSA ratio (cut-off value 0.20) to decide whom to biopsy, we would have diagnosed 16/22 cancers; the difference between these two procedures was not statistically significant (P = 0.17). If we decide to biopsy those patients who have abnormal findings in DRE and/or TRUS and those who have a F/T PSA ratio < 0.20, we would diagnose 20/22 cancers (P = 0.05) and at the same time, reduce the unnecessary biopsies from 80 to 41 (48%). With a PSA value between 4 and 10 ng/mL and no findings in DRE and TRUS and at the same time with a F/T PSA ratio > or = 0.20, we would have to perform biopsies in 20.5 men to find one cancer. On the other hand, in patients with suspicious findings in DRE and/or TRUS and a F/T PSA ratio < 0.20, in every two men that we biopsy we would find one cancer. CONCLUSION: We believe that among patients with PSA values between 4 and 10 ng/mL after performing DRE and TRUS, the additional information of F/T PSA ratio can help since it increases the number of cancers detected and reduces the number of unnecessary biopsies.

Bladder washing flow cytometry assessment of nephrogenic adenoma of the bladder.

A case of nephrogenic adenoma of the bladder is reported. This rare benign lesion that histologically resembles primitive renal collecting tubules is considered to represent a metaplastic response of urothelium to several stimulating factors. DNA flow cytometry performed on preoperative bladder washing revealed an aneuploid phenotype.

A rare case of gigantic calyx dilatation manifested as renal ectopia.

We present a very rare case of gigantic hydrocalycosis which was caused by an obstructed stone. It was so large that it displaced the rest kidney into the contralateral lumbar fossa giving the appearance of a crossed ectopic kidney.

Enzymatic evaluation of renal damage caused by different therapeutic procedures for kidney stone disease.

In an attempt to evaluate renal injury relative to open surgery, percutaneous nephrolithotripsy (PCN) and extracorporeal shock wave lithotripsy (ESWL) were studied in 52 patients with renal calculus disease. Preoperative and postoperative urinary levels of N-acetyl-glycosaminidase (NAG), a sensitive marker of renal tubular damage, were studied. No significant changes were noted in posttreatment urinary NAG values among patients who underwent ESWL or PCN. Although statistically nonsignificant, a constant mild increase of urinary NAG was observed after PCN, that has to be evaluated with long-term follow-up studies. The shock wave number or power in cases treated with ESWL as well as the number of renal punctures in the PCN group did not change the effect on renal tubular function. Diabetics and patients with chronic renal disease treated by ESWL did not show any significant change in posttreatment urinary NAG levels. In contrast to that, all patients treated by open surgery had significant, intense and prolonged increase of the postoperative NAG values, especially those treated by ischaemic nephrolithotomy. Comparing the three different therapeutic modalities, open surgical procedures had the most significant effect on renal function and this difference was statistically significant. We therefore suggest that ESWL does not endanger renal function, while open surgery must be reserved for selected cases.

Encrusted cystitis: aetiology, clinical aspects and management.

Encrusted cystitis is a rare condition characterised by the formation of calcified plaques adherent to or embedded in the bladder mucosa. Although chronic infection with urea-splitting organisms is a prerequisite, other factors seem to play an important role in its development. We report our experience of 4 such cases in which encrusted cystitis presented with various symptoms, produced different pathological abnormalities and was treated by different means in each patient.

Ureaplasma urealyticum and infected renal calculi.

In a group of 41 patients with infection lithiasis, the presence of Ureaplasma urealyticum in urine and in the calculi was investigated. A control group of 27 patients with metabolic lithiasis was simultaneously evaluated. Ureaplasma urealyticum was detected in a total of 10 patients with infection lithiasis. In 7 of those patients, U. urealyticum was the only urease producing microorganism detected, while in the remaining 3 it was detected along with common bacteria. We believe that U. urealyticum may be considered as a possible causative factor of infection lithiasis.

Histological changes of the bladder mucosa following the administration of BCG adriamycin and RO 10-9359.

Three groups of Wistar rats have been treated with intravesical Adriamycin and BCG and oral retinoids. The main effect on the bladder seen on histological sections was mononuclear infiltration in the Adriamycin group, polymorphonuclear infiltration in the BCG group and minimal mononuclear and polymorphous infiltration in the retinoid group. The results are discussed in relation to the existing theories on the protective action of these agents against bladder tumour recurrences.

Acute prostatitis: which antibiotic to use first.

Six antimicrobial agents were administered to 48 patients (divided in 6 groups) who underwent prostatectomy. Half of the patients received the antibiotic in a single dose one hour before the operation and the rest in divided doses 24 hours before the operation. The concentration levels in serum and in prostatic tissue were measured for each of the antibiotics and for each mode of administration. The obtained ratios of prostatic tissue to serum concentrations and the relative antimicrobial activity to local pathogens of each agent indicate that the agent of choice for prostatic disease is netilmicin followed by aztreonam, cefuroxime and the ticarcillin-clavulanic acid combination.

Value of the prostatic LDH levels in the diagnosis of bacterial prostatitis.

Fifty-four patients aged between 21 and 50 years with typical symptoms of chronic prostatitis and 10 healthy men serving as control group had prostatic-fluid cultures according to the Meares-Stamey technique. Prostatic-fluid LDH levels were also estimated by agar gel electrophoresis. Eight patients were found to have bacterial prostatitis and significantly elevated LDH5/LDH1 isoenzymes ratio, 24 patients fulfilled the criteria for nonbacterial prostatitis and 22 patients were classified as suffering from prostatodynia. The LDH5/LDH1 isoenzymes ratio was found to decrease gradually as the inflammatory elements of the prostatic fluid reduced with the lowest value detected in the control group.

Extracorporeal lithotripsy in patients with hemophilia.

Two hemophiliac patients with nephrolithiasis were treated with extracorporeal lithotripsy. Both patients were followed up by the 2nd Hemophilia Center of Athens. One is registered as severe hemophilia A and the other one suffers from hemophilia B. With the cooperation of the specialized center they were prepared as for a major operation by administration of substitution therapy. The least possible number of shock waves at low voltage was administered in order to minimize renal damage. Both patients had an uneventful postoperative course.

[Genetic markers in benign hypertrophy of the prostate]. / Marqueurs génétiques dans l'hypertrophie bénigne de la prostate.

The distribution of phenotypes and gene frequencies of the C3 component of complement, group-specific component, transferrin and haptoglobin were studied in 155 patients with benign prostatic hyperplasia. A statistical analysis of the findings in comparison with the frequency of these genes in the general population failed to demonstrate any correlation between phenotype distribution and benign prostatic hyperplasia.

[Effect of acute distension of the bladder on blood flow and the resistance of the peripheral vessels]. / Le retentissement de la distension aiguë de la vessie sur le débit sanguin et les résistances des vaisseaux périphériques.

The effects of acute, rapid distention of the urinary bladder on the arterial pressure, blood flow and peripheral resistances were studied on dogs and an attempt was made to elucidate the mechanisms of cardiovascular responses observed. In 15 dogs with intact nervous system the arterial blood pressure and blood flow of the femoral, brachial and renal arteries were recorded and the vascular resistances were calculated during an increase of the intra-bladder pressure. Acute distention of the bladder, in the dog, increases arterial blood pressure by 10,25%, the vascular resistance of the femoral and renal vascular bed increases while that of the brachial artery is slightly reduced.

[Disseminated intravascular coagulation syndrome (D.I.C.) and carcinoma of the prostate (author's transl)]. / Syndrome de coagulation intra-vasculaire disséminée (C.I.D.) et cancer de la prostate.

Carcinoma of the prostate, above all when accompanied by bone metastases, may be associated with a disseminated intravascular coagulation syndrome. The problem was to determine whether even in the absence of metastases the coagulation state of prostatic carcinoma patients predisposes them to disseminated intravascular coagulation. The authors compared coagulation equilibrium in 13 patients with a prostatic adenoma and 21 with carcinoma of the prostate free of metastases or infection. Fibrin breakdown product levels were abnormally high in 85.7 % of the carcinoma patients (as against 46.2 % of the adenoma sufferers). Clotting factor XIII was decreased in 70 % of carcinoma patients (as against 48.5 % of those with an adenoma). One prostatic carcinoma patient in four shows evidence of latent intravascular coagulation even in the absence of bone metastases. This prevalence justifies thorough coagulation studies in all patients with carcinoma of the prostate.