Pain perception during transrectal ultrasound guided prostate needle biopsy: an objective analysis of local anesthesia use.

We assessed the effect of periprostatic nerve blockade during transrectal ultrasound of the prostate prior to obtaining systematic needle biopsies and the discomfort associated with this procedure. A prospective randomized study was performed on 100 men requiring systematic needle biopsy of the prostate. Patients were assigned to two groups: Group 1 received no local anesthesia and Group 2 received a periprostatic injection of 5 ml 1% lidocaine solution (2.5 ml bilaterally) prior to undergoing biopsy of the prostate. The patients were asked to respond to a pre- and post-procedural questionnaire which consisted of four questions designed to evaluate pain perception and pain experienced, respectively, during the entire procedure. Mean pain scores for Group 1 responses vs Group 2 responses were not statistically different for any of the pre-procedural questions. Post-procedural pain scores were significantly lower in Group 2 vs Group 1 (control) for questions 1 and 3: question 1 (2.6+/-1.8 vs 3.8+/-1.8, P<0.05), question 2 (3.0+/-1.9 vs 3.7+/-2.1, P=0.14). Question 3 (2.8+/-2.0 vs 4.3+/-1.9, P<0.05), and question 4 (1.6+/-2.4 vs 2.1+/-2.6, P=0.38). During the study, no patient from Group 2 experienced any adverse reaction from the injection. Our data suggest that periprostatic nerve blockade during transrectal ultrasound of the prostate results in less patient discomfort.

The critical role of patient follow-up after receiving a diagnosis of prostatic intraepithelial neoplasia.

With the increasing incidence of prostatic intraepithelial neoplasia being found at the time of prostate biopsy and the association of prostatic intraepithelial neoplasia to coexisting prostate cancer and/or the future development of prostate cancer, patient compliance in following post-biopsy follow-up instructions for re-biopsy is becoming more significant in the detection of prostate cancer at an earlier and, therefore, potentially curable stage. During a 3-y period, we reviewed the charts of 130 patients who received an initial diagnosis of prostatic intraepithelial neoplasia after undergoing transrectal ultrasound of the prostate with biopsy. It is our policy to inform the patient of their diagnosis of prostatic intraepithelial neoplasia at the time of the initial biopsy and to recommend a repeat biopsy in 6-12 months. Patients are informed of the diagnosis of prostatic intraepithelial neoplasia verbally and in writing. In addition, a letter is sent to their referring physician with the re-biopsy recommendation. Thirty-nine of 130 patients (30%) were seen for re-biopsy within the specified time. An additional 36 patients (27.69%) were re-biopsied between 12 and 18 months after the initial diagnosis of prostatic intraepithelial neoplasia. An additional 11 patients (7%) were re-biopsied more than 18 months after their initial diagnosis. Forty-four patients failed to return for re-biopsy. Overall, patient follow-up within the desired protocol was poor and must be improved upon to prevent any delays in the diagnosis of prostate cancer. Prostate Cancer and Prostatic Diseases (2001) 4, 63-66

Patient noncompliance after vasectomy.

OBJECTIVE: To determine the postoperative instruction compliance rate in men undergoing bilateral vasectomy. DESIGN: Retrospective chart review. SETTING: Private practice urological office. PATIENT(S): The records of all patients undergoing vasectomy were reviewed to determine the rate of compliance with postvasectomy follow-up instructions. It is our policy to have the patient continue to use some form of birth control until he achieves two consecutive negative semen analyses 1 month apart. In addition, we recommend a yearly semen analysis after achieving sterility to screen for the rare patient who recanalizes. Postvasectomy follow-up instructions are given to the patient both verbally and in writing. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The records of 1,892 consecutive patients undergoing vasectomy were reviewed, and the results of semen analyses were noted to determine the rate of compliance with postvasectomy follow-up instructions. RESULT(S): Six hundred forty-four men (34%) never returned after vasectomy and, therefore, no semen analyses were available for examination. Six hundred nineteen men (33%) returned for a single semen analysis. Six hundred twenty-nine men (33%) returned for a second negative semen analysis. Only 60 men (3%) completed postvasectomy follow-up instructions and returned for a yearly semen analysis. CONCLUSION(S): The rate of compliance with postvasectomy follow-up instructions for determining sterility is poor.

PIP: To determine the rate of patient compliance with post-vasectomy instructions for verifying sterility, the records of all 1892 men undergoing bilateral vasectomy in a private urological practice in Grand Rapids, Michigan, during 1985-95 were reviewed. Vasectomy acceptors at this practice are instructed to use some form of birth control until 2 consecutive negative semen analyses 1 month apart have been recorded. In addition, a yearly semen analysis is recommended to screen for recanalization. These post-vasectomy instructions are delivered verbally on 1 occasion and 3 times in writing. 644 men (34%) never returned after vasectomy. Another 619 men (33%) returned only for a single semen analysis, even though 36 had a positive test result. 629 men (33%) with an initial negative result returned for a second semen analysis; in 65 cases, the second analysis failed to document azoospermia. A total of 157 men with positive first or second semen analyses never were cleared. Only 60 men (3%) returned for the yearly semen analysis. 8 pregnancies (0.4%) were reported in this series, all of which involved men who had not followed the post-vasectomy protocol. These findings underscore the need for thorough patient education on the importance of the post-vasectomy follow-up.

DNA heterogeneity determined by flow cytometry in prostatic adenocarcinoma--necessitating multiple site analysis.

Although DNA ploidy analysis of prostate cancer is generally associated with grade, stage, clinical outcome, and responsiveness to androgen therapy, one possible reason cited for contrary reports may be tumor heterogeneity. A preliminary report using flow cytometric analysis of punch biopsies demonstrated DNA heterogeneity in five of nine patients. We evaluated 75 patients by cutting whole mounts of formalin fixed prostatectomy tissue every 0.6 cm. All malignant areas and a selected normal area were circumscribed, excised, remounted, and 1-3 50 mu thick sections removed. The nuclei were extracted by a Hedley technique and the DNA stained with propidium iodide. Each whole mount had an average of 1 distinct malignant area (range of 1-6 areas per whole mount block). Nuclei were analyzed on a Becton Dickinson (San Jose, CA) FACScan flow cytometer equipped with RFIT DNA software program. After excluding histograms with CVs > 8.0% and/or "suspicious" diploid histograms having a right "shoulder," 75 or 87 patients still had > or = 2 malignant sites available for analysis (average 4, range 2-9 malignant sites/patient). The 322 histograms had an average CV of 4.4%. Thirty of 75 patients (40%) showed DNA heterogeneity in multiple samples taken from the same prostate. There were 37 prostates with only diploid (D), 1 with only tetraploid (T), 7 with only aneuploid (A), 20 with D plus A, 7 with D plus T, 2 with D plus T plus A, and 1 with a D plus suspected hypodiploid DNA content. Exclusion of the tetraploid and "near diploid aneuploid" cases still resulted in 16% (12/75) of the patients having a diploid versus aneuploid DNA content heterogeneity. Because 40% of the prostates contained a different ploidy depending on which area was sampled, this report suggests multiple sites of malignancy must be analyzed to more accurately assess the ploidy status of prostatic adenocarcinoma.

Comparing clinical staging plus transrectal ultrasound with surgical-pathologic staging of prostate cancer.

Twenty-five men with histopathologic diagnosis of prostatic adenocarcinoma were staged utilizing traditional staging modalities and transrectal ultrasound of the prostate (TRUSP). A comparison was then done with surgical-pathologic stage. TRUSP accurately predicted the local extent of disease in 84 percent of patients, while digital rectal examination understaged in 64 percent of patients. TRUSP is a valuable adjunct to staging prostate cancer prior to definitive therapy.

Transrectal ultrasound and fine needle aspiration for malacoplakia of the prostate.

Clinically, malacoplakia of the prostate gland may mimic prostatic carcinoma. We report a case of prostatic malacoplakia in which transrectal ultrasound of the prostate was most compatible with carcinoma. However, fine needle aspiration cytology and biopsy revealed the classical histopathological features of malacoplakia so that a correct diagnosis could be made.