Inadequacy of biopsy for diagnosis of upper tract urothelial carcinoma: implications for conservative management.

OBJECTIVE: To report changes in grade and stage between initial diagnostic and repeat biopsies or resection for urothelial carcinoma (UTUC) and investigate the consequences for endoscopic management. Ureteroscopic management of upper tract UTUC is an alternative to nephroureterectomy, which is less invasive and preserves renal function. However, concerns about potential understaging, inaccurate grading, incomplete resection, lack of effective tertiary chemoprevention, and need for ureteroscopic surveillance limits it appeal. METHODS: Clinicopathological records of patients with UTUC treated at our institution were reviewed. Fifty-six patients with a histologic diagnosis of UTUC and 2 or more consecutive biopsies or biopsy followed by surgical resection were included, resulting in 65 biopsy specimens. RESULTS: The median interval between diagnostic biopsy and subsequent biopsy or resection was 6 weeks (range, 1 week to 60 months). Change in grade from the diagnostic biopsy occurred in 24 of 65 biopsies (37%), including 9 in which diagnosis changed from low to high grade. Change in the stage from the diagnostic biopsy occurred in 25 of 65 biopsies (38%). Overall, 24 (43%) patients were reclassified from low-grade, noninvasive disease to high-grade and/or invasive disease. CONCLUSION: A change in grade and/or stage from the diagnostic biopsy occurred in more than one third of patients with UTUC managed conservatively. Because of the short median time interval between biopsies, this finding likely represents variability in tumor sampling on biopsy. Because of the concerns of undergrading and understaging, appropriate patient selection and vigilant endoscopic surveillance are mandatory for UTUC managed endoscopically.

Limited warm ischemia during elective partial nephrectomy has only a marginal impact on renal functional outcomes.

PURPOSE: Ischemic damage during partial nephrectomy increases with each minute of warm ischemia, leading some groups to advocate hypothermia in all cases or partial nephrectomy without vascular occlusion as a primary technique. The renal functional implications of these approaches have not been well studied in patients who undergo elective partial nephrectomy. MATERIALS AND METHODS: We evaluated early and late renal functional outcomes in 1,132 patients with 2 functioning kidneys and normal preoperative serum creatinine who underwent partial nephrectomy without regional ischemia (58), with less than 30-minute warm ischemia (809) or with cold ischemia (265). RESULTS: The preoperative, postoperative and latest glomerular filtration rates were not significantly different in the 3 groups. At latest followup the relative decrease in renal function was less in cases without regional ischemia than in those with less than 30-minute warm ischemia and those with cold ischemia (0.5% vs 13% and 11%, respectively, p <0.001). In part this reflected selection bias since tumor size and the amount of parenchyma removed were lowest in that group (p <0.001). On multivariate analysis the percent of parenchyma preserved and the baseline glomerular filtration rate were strongly associated with the postoperative and latest glomerular filtration rates (p <0.001) but the partial nephrectomy approach was not (p >0.05). Adverse short or long-term renal functional outcomes were marginally increased in patients with 20 to 30-minute warm ischemia. However, such events were uncommon and renal failure developed in only 4 of 1,132 patients (less than 0.4%). CONCLUSIONS: During elective partial nephrectomy a warm ischemia time of less than 20 minutes is not associated with clinically relevant functional loss compared to that of alternative techniques. However, longer warm ischemia time may correlate with ischemic injury and should be avoided.

Chronic kidney disease after nephroureterectomy for upper tract urothelial carcinoma and implications for the administration of perioperative chemotherapy.

BACKGROUND: The prevalence of chronic kidney disease (CKD) in patients with upper tract urothelial carcinoma (UTUC) is poorly defined, both before and after nephrouretectomy. Although multimodal treatment paradigms for UTUC are under-developed, this has important implications on patients' ability to receive cisplatin-based combination chemotherapy (CBCC). METHODS: Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula in 336 patients with UTUC, who were treated at the Cleveland Clinic by nephroureterectomy since 1992. An eGFR cutoff of 60 mL/min/1.73 m(2) was used to determine the presence of CKD and eligibility for CBCC. RESULTS: Median age was 72 years and median preoperative eGFR was 59 mL/min/1.73m(2). Before nephroureterectomy, only 48% of patients were eligible to receive CBCC and this decreased to 22% postoperatively (P < .001). In the 144 patients with pT2-pT4 and/or pN1-pN3 disease who are suitable to receive CBCC, these proportions were 40% and 24%, respectively (P = .009). Although 50 patients overall received some form of perioperative chemotherapy, only 3 and 11 patients received neoadjuvant and adjuvant CBCC, respectively. CONCLUSIONS: CKD is prevalent in the UTUC population and a minority of patients has an optimal eGFR to receive neoadjuvant CBCC. Nephrouretectomy may eliminate CBCC as a therapeutic option in 49% of high-risk patients if it is deferred to the adjuvant setting. Multimodal treatment strategies for UTUC should focus on neoadjuvant chemotherapy, as few patients are eligible for adjuvant CBCC because of the substantial decline in eGFR caused by nephroureterectomy.

Active treatment of localized renal tumors may not impact overall survival in patients aged 75 years or older.

BACKGROUND: Although nephrectomy cures most localized renal cancers, this oncologic benefit may be outweighed by the renal functional costs of such an approach. In this study, the authors examined overall survival in 537 patients who had localized renal tumors < or = 7 cm detected at age > or = 75 years to investigate whether surgical intervention improved survival compared with active surveillance. METHODS: Clinical T1 renal tumors were managed with surveillance (20%), nephron-sparing interventions (53%), or nephrectomy (27%). Cox regression models were constructed based on age, comorbidity, management type, renal function, and other variables. RESULTS: The median follow-up was 3.9 years, and death from any cause occurred in 148 patients (28%). The most common cause of death was cardiovascular (29%), and cancer progression was responsible in only 4% of deaths. Kaplan-Meier analysis revealed decreased overall survival for patients who underwent surveillance and nephrectomy relative to nephron-sparing intervention (P = .01); however, surveilled patients were older and had greater comorbidity. In multivariate analysis, significant predictors of overall survival included age (P = .0004) and comorbidity (P < .0001) but not management type (P = .3). Preoperative renal function (P = .006) and comorbidity (P = .005) were predictors of cardiovascular mortality, and nephrectomy was associated with greatest loss of renal function. CONCLUSIONS: In patients aged > or =75 years, surgical management of clinically localized renal cortical tumors was not associated with increased survival. Patients died mostly of cardiovascular causes, similar to the general elderly population. Nephrectomy accelerated renal dysfunction, which was associated with cardiovascular mortality. Current paradigms suggest that there is over treatment of localized renal tumors, and further study will be required to evaluate the advisability of various options in patients with limited life expectancy.

Partial nephrectomy is associated with improved overall survival compared to radical nephrectomy in patients with unanticipated benign renal tumours.

BACKGROUND: Partial nephrectomy (PN) has been associated with improved overall survival (OS) in select cohorts with localised renal masses when compared to radical nephrectomy (RN). The driving forces behind these differences have been difficult to elucidate given the heterogeneity of previously compared cohorts. OBJECTIVE: Compare OS in a subset of patients with unanticipated benign renal masses to minimise the confounding effect of cancer. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively evaluated 2608 consecutive clinical T1 enhancing renal masses that were treated with extirpative surgery at our institution between 1999 and 2006. Of these, 499 tumours (19%) were found to be benign on final pathology. Preoperative data and renal functional data were used to generate a propensity model that was then plugged into a multivariate model of survival. Median follow-up for the entire cohort was 50 mo (interquartile range [IQR]: 32-73). INTERVENTION: All patients underwent PN or RN. MEASUREMENTS: We measured OS and cardiac-specific survival. RESULTS AND LIMITATIONS: Five-year OS estimates for the PN (n=388) and RN (n=111) cohorts were 95% (95% confidence interval [CI], 93-98) versus 83% (95% CI, 74-90), respectively (P<0.0001). On multivariate analysis, controlling for both comorbidity and age, RN was associated with a 2.5-fold increased risk of death compared to PN (hazard ratio [HR]: 2.5; 95% CI, 1.3-5.1). Postoperative estimated glomerular filtration rate (eGFR) was also an independent predictor of OS and cardiac-specific survival (HR: 0.97; 95% CI, 0.95-0.99 and HR: 0.96; 95% CI, 0.93-0.99, respectively). The retrospective nature of this analysis limits the strength of the conclusions. CONCLUSIONS: PN was associated with better OS when compared to RN in patients with unanticipated benign tumours. This observed survival advantage appears partly to be the result of better preservation of eGFR, but other kidney functions or unmeasured factors may also play a role. These data indicate that PN should be aggressively pursued in any patient where PN is technically feasible.

Elective partial nephrectomy in patients with clinical T1b renal tumors is associated with improved overall survival.

OBJECTIVES: Elective partial nephrectomy (PN) in patients with cT1b renal tumors is relatively unstudied. Most surgeons currently only perform radical nephrectomy (RN) in this population. Patients with localized kidney cancer may die from disease, but the risk of a non-cancerrelated death is significant and may be worsened by nephrectomy-induced chronic kidney disease (CKD). PN may offer the perfect combination of cancer control and preservation of renal function; therefore we compared overall and cancer-specific survival in patients treated for cT1b renal masses. METHODS: From 1999 to 1906, 510 patients with renal tumors >4-7 cm, a glomerular filtration rate (GFR) >60, and a normal contralateral kidney underwent extirpative surgery (PN, n = 212 or RN, n = 298) at our institution. As the patients were not randomized, we generated a propensity model based on preoperative patient characteristics to control for selection bias. RESULTS: Cancer-specific survival was similar between cohorts when compared by pathologic stage and grade. On multivariate analysis, RN was associated with postoperative CKD (odds ratio 3.4, 95% confidence interval [CI] 2.1-5.6). Survival analysis demonstrated that when controlling for the propensity score, PN was associated with better overall survival (hazard ratio 0.30, 95% CI = .13-.71). CONCLUSIONS: Where technically feasible, PN offers cancer control equivalent to that of RN. Elective PN was associated with a significantly better overall survival in this cohort, even when controlling for age, tumor size, pathologic stage, and burden of comorbid diseases. The improvement in overall survival appears to be attributable in part to prevention of postoperative CKD.

Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses.

PURPOSE: Radical nephrectomy has traditionally been preferred to partial nephrectomy in patients with localized renal cell cancer because of its simplicity and established cancer control. Recent data suggest that these patients have significant competing risks of death, some of which may be increased by chronic renal insufficiency. Therefore, we compared overall survival, cancer specific survival and cardiac specific survival in patients undergoing partial or radical nephrectomy for cT1b tumors. MATERIALS AND METHODS: From 1999 to 2006, 1,004 patients with renal masses between 4 and 7 cm underwent extirpative surgery, partial nephrectomy (524) or radical nephrectomy (480). We generated a propensity model based on preoperative patient characteristics, and then modeled survival with the additional variables of pathological stage and new baseline renal function. RESULTS: On multivariate analysis cancer specific survival was equivalent for patients treated with partial nephrectomy or radical nephrectomy. Those patients undergoing radical nephrectomy lost significantly more renal function than those undergoing partial nephrectomy. The average excess loss of renal function observed with radical nephrectomy was associated with a 25% (95% CI 3-73) increased risk of cardiac death and 17% (95% CI 12-27) increased risk of death from any cause on multivariate analysis. CONCLUSIONS: Partial nephrectomy offers cancer specific survival equivalent to that of radical nephrectomy and is technically feasible in at least 50% of patients with cT1b tumors. Preservation of renal function was significantly better in patients treated with partial nephrectomy. Postoperative renal insufficiency was a significant independent predictor of overall and cardiovascular specific survival, and efforts should be made to limit the renal function loss associated with surgery for localized renal masses.

Performance of the chronic kidney disease-epidemiology study equations for estimating glomerular filtration rate before and after nephrectomy.

PURPOSE: Accurate renal function determination before and after nephrectomy is essential for proper prevention and management of chronic kidney disease due to nephron loss and ischemic injury. We compared the estimated glomerular filtration rate using several serum creatinine based formulas against the measured rate based on (125)I-iothalamate clearance to determine which most accurately reflects the rate in this setting. MATERIALS AND METHODS: Of 7,611 patients treated at our institution since 1975 the measured glomerular filtration rate was selectively determined before and after nephrectomy in 268 and 157, respectively. Performance of the Cockcroft-Gault, Modification of Diet in Renal Disease Study, re-expressed Modification of Diet in Renal Disease Study and Chronic Kidney Disease-Epidemiology Study equations, each of which estimates the glomerular filtration rate, were determined using serum creatinine, age, gender, weight and body surface area. The performance of serum creatinine, reciprocal serum creatinine and the 4 formulas was compared with the measured rate using Pearson's correlation, Lin's concordance coefficient and residual plots. RESULTS: Median serum creatinine was 1.4 mg/dl and the median measured glomerular filtration rate was 50 ml per minute per 1.73 m(2). The correlation between serum creatinine and the measured rate was poor (-0.66) compared with that of reciprocal serum creatinine (0.78) and the 4 equations (0.82 to 0.86). The Chronic Kidney Disease-Epidemiology Study equation performed with greatest precision and accuracy, and least bias of all equations. Stage 3 or greater chronic kidney disease ((125)I-iothalamate glomerular filtration rate 60 ml per minute per 1.73 m(2) or less) was present in 44% of patients with normal serum creatinine (1.4 mg/dl or less) postoperatively. Such missed diagnoses of chronic kidney disease decreased 42% using the Chronic Kidney Disease-Epidemiology Study equation. CONCLUSIONS: Glomerular filtration rate estimation equations outperform serum creatinine and better identify patients with perinephrectomy compromised renal function. The newly developed, serum creatinine based, Chronic Kidney Disease-Epidemiology Study equation has sufficient accuracy to render direct glomerular filtration rate measurement unnecessary before and after nephrectomy for cause in most circumstances.

Management of the adrenal gland during partial nephrectomy.

PURPOSE: Nephron sparing surgery is an increasingly used alternative to Robson's radical nephroadrenalectomy. The indications for adrenalectomy in patients undergoing partial nephrectomy are not clearly defined and some surgeons perform it routinely for large and/or upper pole renal tumors. We analyzed initial management and oncological outcomes of adrenal glands after open partial nephrectomy. MATERIALS AND METHODS: Institutional review board approval was obtained for this study. During partial nephrectomy the ipsilateral adrenal gland was resected if a suspicious adrenal nodule was noted on radiographic imaging, or if intraoperative findings indicated direct extension or metastasis. RESULTS: Concomitant adrenalectomy was performed in 48 of 2,065 partial nephrectomies (2.3%). Pathological analysis revealed direct invasion of the adrenal gland by renal cell carcinoma (1), renal cell carcinoma metastasis (2), other adrenal neoplasms (3) or benign tissue (42, 87%). During a median followup of 5.5 years only 15 patients underwent subsequent adrenalectomy (0.74%). Metachronous adrenalectomy was ipsilateral (10), contralateral (2) or bilateral (3), revealing metastatic renal cell carcinoma in 11 patients. Overall survival at 5 years in patients undergoing partial nephrectomy with or without adrenalectomy was 82% and 85%, respectively (p = 0.56). CONCLUSIONS: Adrenalectomy should not be routinely performed during partial nephrectomy, even for upper pole tumors. We propose concomitant adrenalectomy only if a suspicious adrenal lesion is identified radiographically or invasion of the adrenal gland is suspected intraoperatively. Using these criteria adrenalectomy was avoided in more than 97% of patients undergoing partial nephrectomy. Even using such strict criteria only 13% of these suspicious adrenal nodules contained cancer. The rarity of metachronous adrenal metastasis and the lack of an observable benefit to concomitant adrenalectomy support adrenal preservation during partial nephrectomy except as previously outlined.

Factors predicting renal functional outcome after partial nephrectomy.

PURPOSE: Compared to radical nephrectomy, partial nephrectomy better preserves renal parenchyma and function. Although several clinical factors may impact renal function after partial nephrectomy including preoperative function, age, gender and comorbidities, the contributions of tumor and surgical factors have not been well studied. We evaluate independent factors predicting functional outcomes after partial nephrectomy. MATERIALS AND METHODS: Preoperative and all postoperative serum creatinine values for 1,169 patients undergoing partial nephrectomy were used to estimate glomerular filtration rate. Postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate were analyzed using multiple pertinent covariates. RESULTS: Median preoperative, postoperative nadir and ultimate glomerular filtration rates were 77, 57 and 71 ml per minute per 1.73 m(2), respectively. Increasing age, gender, lower preoperative glomerular filtration rate, solitary kidney, tumor size, ischemia time and longer time to nadir glomerular filtration rate significantly predicted postoperative nadir glomerular filtration rate and ultimate glomerular filtration rate. Acute loss of renal function predicted lower ultimate glomerular filtration rate. In the entire cohort, in patients with normal preoperative renal function, and in those with baseline stage 3 and those with stage 4 chronic kidney disease the incidence of postoperative acute kidney injury after partial nephrectomy was 3.6%, 0.8%, 6.2% and 34%, and the incidence of chronic end stage renal disease after partial nephrectomy was 2.5%, 0.1%, 3.7% and 36%, respectively. CONCLUSIONS: Lower preoperative glomerular filtration rate, solitary kidney, older age, gender, tumor size and longer ischemic interval all predicted lower glomerular filtration rate after partial nephrectomy. Therefore, duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, and efforts to limit ischemic time and injury should be pursued in open and laparoscopic partial nephrectomy.

Blood pressure surges during office-based transurethral microwave therapy for the prostate.

OBJECTIVE: To investigate the occurrence of adverse blood pressure (BP) events during transurethral microwave therapy (TUMT) for benign prostatic hyperplasia. PATIENTS AND METHODS: We conducted a retrospective study of the vital signs of 185 consecutive patients who received TUMT (via 6 devices) at 4 institutions from March 1, 2003, to September 18, 2005. Maximum change, percent change in systolic BP, diastolic BP, mean arterial pressures, heart rate, and oxygen saturation were evaluated. RESULTS: Of the 185 patients, 77 patients (42%; 95% confidence interval [CI], 35%-49%) experienced an increase in systolic BP of more than 30 mm Hg during TUMT; 30 patients (16%; 95% CI, 12%-22%), an increase of more than 50 mm Hg; and 10 patients (5%; 95% CI, 3%-10%), an increase of more than 70 mm Hg. A greater than 20% change in systolic BP from baseline was observed in 95 patients (51%; 95% CI, 44%-58%). Many men experienced multiple events, with an average time of onset of 15.9 minutes into treatment. Significant differences were noted among the devices. CONCLUSION: This retrospective study demonstrates a significant number of BP surges during TUMT for benign prostatic hyperplasia. These BP changes represent a potential risk of cardiovascular events in patients with known or occult cardiovascular disease. Our study is the first to recognize the incidence of this BP response. Until further studies identify the mechanisms responsible for these surges in BP, the results of this study suggest that BP should be monitored, treatment adjusted, and antihypertensive medications continued during all TUMT.

Pathological aggressiveness of prostatic carcinomas related to RNASEL R462Q allelic variants.

PURPOSE: Allelic variations in the HPC1/RNASEL gene, especially the R462Q single nucleotide polymorphism, have been associated with increased susceptibility to prostate cancer. Prior studies have suggested that HPC1 or R462Q associated tumors present with more aggressive clinical features. We assessed a series of men undergoing radical prostatectomy for clinical and pathological measures of tumor aggressiveness according to the RNASEL R462Q genotype. MATERIALS AND METHODS: A prospective analysis of 232 men treated for prostate cancer with radical prostatectomy was performed. Disease aggressiveness at diagnosis was assessed by age at disease onset, biopsy Gleason score, clinical T stage and pretreatment prostate specific antigen. Tumor aggressiveness was assessed pathologically by tumor volume, extraprostatic extension, seminal vesicle involvement and lymph node metastasis. Clinical and pathological characteristics were then correlated with RNASEL genotype. RESULTS: Of the 232 men studied 104 (45%) were homozygous WT, 101 (43%) were heterozygous and 27 (12%) were homozygous for the R462Q variant, mirroring the distribution in the general population. No significant differences were seen between genotypes in age at disease onset, pretreatment characteristics or pathological features, as assessed by surgical grade and pathological stage. Tumors homozygous for the R462Q variant were of smaller volume than other genotypes (p = 0.02). CONCLUSIONS: This prospective study suggests that prostate cancer in patients with the R462Q allelic variant of the HPC1/RNASEL gene is not associated with more aggressive clinical or pathological features in radical prostatectomy specimens.

Interstitial temperature mapping during Prolieve transurethral microwave treatment: imaging reveals thermotherapy temperatures resulting in tissue necrosis and patent prostatic urethra.

OBJECTIVES: Temperature mapping of the prostate during transurethral microwave thermotherapy and imaging of the resultant zones of tissue necrosis have been previously performed using several commercial systems. This study was performed using the Prolieve Thermodilatation System, which simultaneously compresses the prostate with a 46F balloon circulating heated fluid and delivering microwave energy into the prostate. METHODS: Interstitial temperature mapping during Prolieve treatment was performed on 10 patients with benign prostatic hyperplasia using 24 temperature sensors arrayed throughout the prostate. Voiding cystourethrograms were performed on 3 additional patients treated without temperature mapping to document the patency of the prostatic urethra 1 hour after treatment. Gadolinium-enhanced magnetic resonance imaging studies were performed on all patients 1 week after treatment to determine the extent and pattern of tissue necrosis resulting from transurethral microwave thermotherapy. RESULTS: Interstitial temperature mapping found that the heating pattern generated by the Prolieve system created average peak temperatures of 51.8 degrees C an average of 7 mm away from the prostatic urethra. These temperatures were greater near the bladder neck and mid-gland than toward the prostatic apex. Subtherapeutic temperatures were seen adjacent to the urethra, consistent with the viable tissue seen on gadolinium-enhanced magnetic resonance imaging sequences. Magnetic resonance imaging also revealed necrotic zones that were consistent with sustained temperatures greater than 45 degrees C. Voiding cystourethrograms showed widely patent prostatic urethras 1 hour after treatment. CONCLUSIONS: Transurethral microwave thermotherapy with the Prolieve Thermodilatation System produced sustained therapeutic temperatures that resulted in tissue necrosis while maintaining viable tissue surrounding a temporarily dilated prostatic urethra.

Transurethral microwave thermotherapy effectiveness in small prostates.

OBJECTIVES: To dispel the misconceptions that patients with small prostates react differently than patients with larger prostates to cooled transurethral microwave thermotherapy. Cooled transurethral microwave thermotherapy has developed into a valid alternative to treat men with lower urinary tract symptoms due to benign prostatic hyperplasia. However, doubts still remain regarding the ability of this office-based technique to treat smaller prostates. METHODS: A database of 713 men from six previous studies using cooled transurethral microwave thermotherapy devices developed by Urologix were combined for this analysis. The data were analyzed to determine whether the baseline prostate size had a significant effect on American Urological Association Symptom Index, peak flow rate, quality-of-life score, or symptom problem index. Follow-up intervals in this analysis include 6, 12, 24, 36, 48, and 60 months after therapy. Visual analog scale ratings during treatment were also assessed. General linear models and repeated measures analyses were performed. RESULTS: Statistical analysis showed no effect of baseline prostate size on treatment outcomes for more than 5 years. Visual analog scale measurements were also not affected by the baseline prostate size. CONCLUSIONS: Transurethral microwave thermotherapy appears to be as efficacious in treating patients with small prostates as those with large prostates and should be offered as a treatment modality to patients with prostates of all sizes.

Intraprostatic injection of alcohol gel for the treatment of benign prostatic hyperplasia: preliminary clinical results.

Benign prostatic hyperplasia (BPH) is one of the most common diseases ailing older men. Office-based procedures offer the advantage of being more effective than medications, while limiting the adverse effects, cost, and recovery of surgery. This study presents preliminary data on a new procedure that utilizes intraprostatic alcohol gel injection to ablate prostatic tissue. The purpose of this study is to evaluate the feasibility of using this gel as a treatment for BPH. A total of 65 patients with lower urinary tract symptoms (LUTS) due to BPH were treated with intraprostatic injections of alcohol gel. The gel is composed of 97% denatured alcohol and a patented polymer to cause viscosity. Three different methods of injection were utilized: transrectal (TR) injections (8), transurethral (TU) injections (36), and transperineal (TP) injections guided by biplaned ultrasound (21). Each method provided easy access to the center of the prostate, where a volume of gel, approximately 20-30% of the prostatic volume, was injected. Follow-up was based on changes in peak urinary flow (Qmax), IPSS scores, quality of life scores (QoL), adverse effects, and failures. Data are available at 3 and 12 months. The procedure was well tolerated with only local or no anesthesia in the TR and TP groups; the TU group received spinal anesthesia. All groups showed statistically significant (p < 0.0001) improvements in Qmax, IPSS, and QoL. The mean amount of gel injected was 8.05 ml, representing 21.56% of the prostatic volume. Qmax increased from a baseline mean of 8.50 to 12.01 ml/s at 3 months, and to 11.29 ml/s at 12 months. IPSS scores improved from a baseline mean of 21.12 to 10.00 at 3 months, and to 11.84 at 12 months. QoL scores were only available for 55 patients. QoL scores improved from a baseline of 3.93 to 1.98 at 3 months, and to 2.18 at 12 months. No extraprostatic injury or adverse effects were reported due to treatment. This preliminary study presents significant results showing that intraprostatic injection of alcohol gel could be an option for the treatment of BPH and LUTS. The viscosity of the gel allows for accurate imaging under ultrasound, no run back along the needle allowing for multiple methods of delivery, and the gel does not spread to extraprostatic tissue. This new technique could provide a simple and possibly less expensive clinic procedure for treating BPH, and warrants further study.

Gadolinium-enhanced MRI in the evaluation of minimally invasive treatments of the prostate: correlation with histopathologic findings.

OBJECTIVES: To explore the use of magnetic resonance imaging (MRI) with gadolinium enhancement as a noninvasive method to image the extent of ablation after minimally invasive treatment. Minimally invasive methods for ablating prostatic tissue have emerged as a viable option in the treatment of prostate disease. As these devices enter the mainstream of patient care, imaging methods that verify the exact location, extent, and pattern of the ablation are needed. METHODS: Nineteen patients with prostate cancer were evaluated. All received some type of minimally invasive treatment, post-treatment gadolinium-enhanced MRI sequences, and radical retropubic prostatectomy for histopathologic evaluation. Visual comparisons of gadolinium defects and areas of coagulation necrosis as seen on histopathologic evaluation were made by us. Volumetric and two-dimensional area measurements of the ablation lesions were also compared for correlation between the MRI and histopathologic results. RESULTS: Gadolinium-enhanced MRI could be matched to histopathologic findings by visual comparison in 17 of the 19 cases. Surgically distorted histopathologic specimens and a small periurethral lesion caused 2 patients to have MRI and histopathologic results that could not be matched. Complete volumetric measurements were available for 16 of the 19 patients and correlated strongly (r = 0.924). The two-dimensional area data for all patients also showed significant correlation (r = 0.886). CONCLUSIONS: Correlation with histopathologic findings showed gadolinium-enhanced MRI to be useful for determining the location, pattern, and extent of necrosis caused within the prostate by minimally invasive techniques. Gadolinium-enhanced MRI gives the urologist a useful tool to evaluate the effectiveness of new minimally invasive therapies.

Histological changes of minimally invasive procedures for the treatment of benign prostatic hyperplasia and prostate cancer: clinical implications.

PURPOSE: Benign prostatic hyperplasia (BPH) is near universal in aging men, creating tremendous costs in morbidity and surgical treatment. In the last decade numerous nonsurgical minimally invasive methods have emerged for ablation of prostatic tissue. MATERIALS AND METHODS: We reviewed the recently published English language literature on minimally invasive techniques for treating BPH and cancer with an emphasis on histopathological findings. RESULTS: We compared the spectrum of contemporary minimally invasive treatments for BPH and cancer, with an emphasis on histopathological results. Clinical results were summarized briefly for each treatment method. These procedures ablate tissue by thermal, cryogenic, chemical or enzymatic injury. The 5-year results for some techniques were promising, although long-term durability is still uncertain, and other methods were in preclinical or early clinical stages. Invariably the treated tissue was devitalized with a thin border of granulation tissue and fibrosis. These procedures have applications for BPH and prostate cancer, although some studies are limited to only 1 disease. CONCLUSIONS: Minimally invasive procedures show promise of a durable replacement for surgical resection.