[Structure of a medical article]

The publication of medical research results requires that articles are drafted with a current well-codified structure that must be respected to convince the editorial board of a review and then its readers. The title must be short and relevant in order to best reflect the contents of the article and to allow its effective search on the Internet. The universally adopted structure is the IMRAD (Introduction Methods, Results and Discussion). The introduction is a prerequisite; it presents current knowledge on the problem studied, justifies the subject of the work and specifies its objective within this context. The "Methods" section describes the population, the type of study and its methodology, the equipment used, the primary and secondary end-points studied as well as the statistical methods used for analysis. The "Results" section describes the raw results associated with the statistical tests illustrated by relevant tables and figures. The "Discussion" section is used to underline results that are considered to be important and to compare them with those already published in the field. It may also contain comments on potential bias and suggest the impact of the results on daily practice and/or future research. A conclusion may finalize the discussion or form the subject matter for an independent section. Lastly, all articles include a relevant summary and a suitable bibliography.

[Clinical practice guidelines (CPG): are they useful? Example of the benign prostatic hyperplasia (BPH)]

Clinicians develop routine strategies with multiple and sometimes hardly relevant origins. The logical theoretical solution would be to make available systematically drafted clinical practice guidelines (CPG) with the aim of helping the physician during daily practice. These CPG summarize the best available proofs and relate each recommendation to a level of proof. However, if the CPG is not rigorously drafted, their usefulness is questionable. The AGREE scale, translated into several languages and used by several european countries, including France (ANAES), is useful for the evaluation of the quality of drafting of a CPG but also as a guide when making a CPG. The analysis of different CPG for the management of benign prostatic hyperplasia (HBP) originating from different countries and companies shows important variations which are best explained by large differences in the rigour of drafting. Besides, whatever the quality of the CPG, they too often neglect the key element which is its application in practice. A survey of the modalities of prescription of subsequent examinations in France in HBP demonstrates an important disparity between CPG and routine attitudes in clinical practice. A potential solution may require a deeper involvement of the learned urologic society in the drafting and distribution of the CPG.

Sperm cryopreservation for male patients with cancer: an epidemiological analysis at the University of Pennsylvania

Many cancers strike young males who have not yet started or completed families. Since cancer treatments such as chemotherapy and radiation can irreversibly affect spermatogenesis, sperm cryopreservation is an important option for storing male reproductive potential. In this report, we review our database of 10 years of experience with cryostorage for male cancer patients. We assess types of cancer, timing of collection, sperm quality, and utilization for reproductive purposes. We also report specimen disposal and rates of patient death. There were a total of 164 oncology patients electing to freeze sperm at our institution during the study period. Types of cancer were varied, with testicular cancer, Hodgkin's lymphoma, leukemia, and gastrointestinal cancers comprising the largest groups. Evaluation of semen parameters for these groups revealed that oligospermia, even prior to initiation of cancer therapy, was common. Sperm counts, motility, and morphology did not differ by type of cancer. Interestingly, less than 5% of patients utilized their specimens for reproductive purposes. Seven insemination cycles yielded no pregnancies, while one of two IVF attempts and the single ICSI case were successful. In conclusion, the epidemiological review of our database suggests that sperm cryostorage for fertility preservation in male cancer patients is under-utilized. Additionally, there is minimal use of cryopreserved specimens for reproductive purposes. We speculate that this under-utilization may be due to the paucity of reports regarding reproductive outcome after freezing. It is our objective to provide a compilation of data that will prove useful to both physicians and patients who are considering sperm cryopreservation.

A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same?

OBJECTIVE

To compare overall and methodological quality with content in national and supra-national Clinical Practice Guidelines (CPGs) on benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), as the purpose of CPGs is to reduce unwanted variation in practice and improve patient care by setting agreed standards based on the best available evidence.

METHODS

An electronic search was used to identify Internet-based national and supra-national CPGs on BPH and LUTS available in 2001. Two independent assessors analysed the content and appraised the methodological quality of the CPGs using an existing and validated instrument (St. George's Hospital Medical School Health Care Evaluation Unit Appraisal Instrument) comprising 37 items grouped into three broad areas, i.e. rigour of development, context and content, and clinical application.

RESULTS

Eight CPGs were suitable for appraisal; there was much variation in overall and methodological quality. There was agreement that a patient history and physical examination (including a digital rectal examination) should be used in all symptomatic men. In addition, patients' symptoms should be assessed using a validated symptom score, e.g. the International Prostate Symptom Score. There was considerable variation in the number and type of diagnostic tests recommended for routine assessment. CPGs scoring low on the appraisal instrument (indicating poor overall and methodological quality) were more likely to recommend more diagnostic tests than those scoring high. There was general agreement between the guidelines on the treatment of BPH/LUTS and the importance of the patient's involvement in making management decisions. Guideline quality was independent of local health resources and publication year.

CONCLUSION

The overall and methodological quality of CPGs on BPH/LUTS varies considerably. There appears to be an inverse relationship between guideline quality and the number of diagnostic tests recommended for routine assessment. Using CPGs of high quality may prevent men with BPH/LUTS being exposed to tests of doubtful utility. Although this may reduce both resource use and exposure to potential harm, moving to a more minimalist approach to diagnosis may itself be potentially harmful to patients.

Obesity in relation to prostate cancer risk: comparison with a population having benign prostatic hyperplasia

OBJECTIVE

To analyse the relationship between obesity and prostate cancer, when compared with men with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

The records were reviewed of consecutive patients with histologically confirmed prostate cancer admitted for prostate surgery between January 1993 and February 1999. Controls were selected from patients who were hospitalized at the same time for the surgical treatment of BPH. One control was matched to each case by age. Obesity was defined as a body mass index (BMI) of> 29 kg/m2.

RESULTS

The study included 194 cases and 194 controls; their median (range) age at operation was 69.5 (50-88) years in both groups, and the BMI 26.1 (16.6-38.1) kg/m2 in the cancer and 25.7 (15.1-36.8) kg/m2 in the BPH group. The difference between the groups was not significant (P = 0.06). Obesity was significantly associated with prostate cancer, with an odds ratio (95% confidence interval) of 2.47 (1.41-4.34). Cases with advanced disease had a higher BMI than those with localized disease, but when age was considered the difference was not significant.

CONCLUSION

In general the BMI was not significantly associated with prostate cancer when compared with men having BPH. However, obese men had 2.5 times the risk of having prostate cancer.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.

MATERIALS AND METHODS

Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.

RESULTS

The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).

CONCLUSIONS

The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.

MATERIALS AND METHODS

Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.

RESULTS

The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).

CONCLUSIONS

The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

Copper deficiency induced by tetrathiomolybdate suppresses tumor growth and angiogenesis

Copper plays an essential role in promoting angiogenesis. Tumors that become angiogenic acquire the ability to enter a phase of rapid growth and exhibit increased metastatic potential, the major cause of morbidity in cancer patients. We report that copper deficiency induced by tetrathiomolybdate (TM) significantly impairs tumor growth and angiogenesis in two animal models of breast cancer: an inflammatory breast cancer xenograft in nude mice and Her2/neu cancer-prone transgenic mice. In vitro, TM decreases the production of five proangiogenic mediators: (a) vascular endothelial growth factor; (b) fibroblast growth factor 2/basic fibroblast growth factor; (c) interleukin (IL)-1alpha; (d) IL-6; and (e) IL-8. In addition, TM inhibits vessel network formation and suppresses nuclear factor (NF)kappaB levels and transcriptional activity. Our study suggests that a major mechanism of the antiangiogenic effect of copper deficiency induced by TM is suppression of NFkappaB, contributing to a global inhibition of NFkappaB-mediated transcription of proangiogenic factors.

Acute bacterial endocarditis secondary to transrectal ultrasound-guided prostatic biopsy

We report the first case of a patient with no history of diabetes or cardiac problems who developed an endocarditis secondary to a transrectal prostatic biopsy. Urinalysis prior to the biopsy was normal and the patient had a course of ciprofloxacin 2 hours preoperatively.

[Urinary leukocytes as a new prognostic marker of therapeutic response and of adverse effects associated with the maintenance treatment with endovesical BCG, for the prophylaxis of superficial bladder tumors]

The use of Bacillus Calmette-Guérin (BCG) vaccine as immunotherapy for superficial bladder cancer constitutes a major progress, although it remains limited by the development of adverse effects and problems related to safety. No individual tool is currently available in clinical practice to predict the efficacy or adverse effects of BCG therapy. These problems are accentuated in the case of maintenance therapy according to the protocol of D.L. Lamm.

OBJECTIVES

To define whether the urinary leukocyte count observed after intravesical BCG instillation could be associated with adverse effects and efficacy of treatment.

MATERIAL AND METHODS

A cohort of 72 consecutive patients (518 instillations) was studied prospectively. We defined four classes of adverse effects associated with BCG, according to their type, severity and duration. In combination with this classification, we performed systematic optical urinary leukocyte count on the third day after each instillation (KOVA-Slide 10).

RESULTS

A high urinary leukocyte count (cut-off value: 165,000/ml) was correlated with absence of recurrence (p = 0.009). The adverse effect classification also demonstrated that urinary leukocyte count was related to the severity and duration of adverse effects (p < 0.0001). Median values observed for class I, II and III adverse effects were 40,000 leukocytes/ml, 150,000 leukocytes/ml and 350,000 leukocytes/ml, respectively. No class IV adverse effects were observed. The risk of developing class III adverse effects was increased when the urinary leukocyte count was greater than 86,000 leukocytes per ml.

CONCLUSION

These results suggest a probable relationship between efficacy and safety of BCG, during maintenance therapy. Randomized prospective studies are necessary to evaluate urinary leukocyte count as a tool for adaptation and optimization of BCG therapy.

Tumor progression and survival in patients with T1G3 bladder tumors: multicentric retrospective study comparing 94 patients treated during 17 years

OBJECTIVES

To compare tumor recurrence, progression, and patient survival in T1G3 bladder tumors treated with transurethral resection (TUR) alone, early cystectomy, or TUR with an adjuvant 6-week course of bacille Calmette-Guérin (BCG) and followed up for a minimum of 5 years.

METHODS

Between 1979 and 1996, 94 patients with T1G3 bladder tumors (lamina propria invasion) were treated at nine different centers. The time to tumor recurrence, tumor stage and grade progression, number of delayed cystectomies, and patient survival were analyzed retrospectively in relation to the initial treatment.

RESULTS

The mean follow-up was 62 months. Thirty patients were treated by TUR alone (32%), 50 patients by TUR plus BCG (53%), and 14 patients by primary cystectomy (15%). The recurrence, progression, and cystectomy rates were significantly different between patients treated by TUR alone and TUR plus BCG (Fisher's exact test, P = 0.0005, P = 0.02, and P = 0.005, respectively). The disease-free survival was also significantly different when comparing TUR plus BCG with TUR alone or primary cystectomy (Kaplan-Meier analysis, log-rank test, P = 0.02).

CONCLUSIONS

Endoscopic resection plus BCG treatment of pT1G3 tumors allows an 80% rate of disease-free 5-year survival with bladder preservation. This conservative option has been widely accepted as first-line treatment, offering good cancer control with excellent quality of life. Very accurate surgical and pathologic evaluations before treatment and lifelong follow-up are obviously required.

A prospective radiological anatomical study of the variations of the position of the colon in the left pararenal space

Percutaneous puncture of the kidney allows direct access to the pyelocalicial cavities. The posterior approach of this retroperitoneal organ can be complicated of transcolic punctures due to the postrenal position of the colon. A prospective radiological anatomical study of the relationship between the left kidney and the descending colon was undertaken. One hundred computed tomograms of adult subjects were obtained from which the anatomy of the left perirenal area was determined: the descending colon is more frequently behind the kidney in the young females. Two main factors determinants of this situation are: 1) colon ontogenesis in relation to the attachment of the primitive mesocolon, permitting a 'fixed' left colon, or 'moving' left colon at the end of a long mesocolon, allowing it to pass behind the kidney; 2) a mechanical factor whereby the accumulation of perirenal fat with increasing age may be a limiting factor in lateral displacement of the colon.

[Tolerance and efficiency of intravesical instillation of Calmette-Guérin in the prophylactic treatment of superficial bladder tumors, using a maintenance treatment]

Maintenance treatment with complementary BCG instillations in the prevention of superficial bladder tumour could improve the results of this immunotherapy. This maintenance treatment is limited by accentuation of the adverse effects related to BCG.

OBJECTIVES

To evaluate the impact of maintenance treatment on tumour recurrence and progression, and to evaluate the influence of adverse effects on maintenance treatment and the recurrence rate.

MATERIAL AND METHODS

72 patients were treated with six weekly instillations of 81 mg of BCG (Immucyst) followed by three complementary instillations 3, 6, 12, 18, 24, 30 and 36 months later. Adverse effects (AE) were classified into four classes, according to their type, severity and duration, and were recorded prospectively for 518 instillations. An adverse effect score was determined for each patient.

RESULTS

84.9% of patients did not present any recurrence, 12.5% developed recurrence and 2.6% progressed. The instillation regimen was completed by 19% of patients, the dose had to be decreased for 57% of patients and treatment had to be discontinued for 39% of patients. An initial adverse effect score (AESi) greater than 1.5 was associated with an increased risk of discontinuation of treatment or reduction of the dosage during maintenance treatment (p = 0.01).

CONCLUSIONS

Maintenance treatment was associated with a very low recurrence and progression rate. We have established and validated an adverse effect severity scale and the consequences of these adverse effects on maintenance treatment. This scale could be used to prospectively define the most appropriate maintenance instillation regimen, by preventively decreasing the doses or deferring instillation.

Tolerability of bacille Calmette-Guérin maintenance therapy for superficial bladder cancer

OBJECTIVES

To study the influence of adverse reactions on adherence to an immunotherapy maintenance schedule and the recurrence rate of bladder cancer. Bacille Calmette-Guérin immunotherapy has documented efficacy in the management of high-risk superficial bladder cancer. However, the optimal duration of intravesical bacille Calmette-Guérin therapy and the risk/benefit ratio of maintenance therapy are controversial.

METHODS

From April 1996 to April 2000, 72 patients with superficial bladder cancer were treated with Immucyst (six consecutive weekly instillations of 81 mg) and then received maintenance therapy consisting of three consecutive weekly instillations 3, 6, 12, 18, 24, 30, and 36 months later. Adverse reactions, studied during 518 instillations, were classified in four categories using a scale based on the World Health Organization recommendations, and their impact on the adherence to therapy was analyzed.

RESULTS

After an average follow-up of 24 months, a durable disease-free response was observed in 84.9% of the patients; 12.5% of patients had a relapse and 2.6% had disease progression. The response rate was similar in patients with and without adverse reactions. Only 14 patients (19%) received all the scheduled maintenance instillations. The dose was reduced in 41 patients (57%), and treatment was stopped in 28 patients (39%). In multivariate analysis, an adverse event score of 1.5 or greater during induction therapy was significantly associated with cessation or modification of maintenance therapy (P = 0.01).

CONCLUSIONS

The scale developed in this study to monitor the adverse reactions to bacille Calmette-Guérin and their impact on the adherence to maintenance therapy may be helpful for tailoring maintenance regimens or implementing protective measures (dose reduction or treatment postponement).

Leukocyturia as a predictor of tolerance and efficacy of intravesical BCG maintenance therapy for superficial bladder cancer

OBJECTIVES

To examine leukocyturia as a predictor of tumor recurrence and occurrence of adverse events after bacille Calmette-Guérin (BCG) immunotherapy. The use of BCG immunotherapy, a very major advance in the management of superficial bladder cancer, is limited by the frequency of adverse events. As yet, we have no way of predicting the efficacy and tolerability of BCG instillation in clinical practice. This problem is even more acute during BCG maintenance therapy.

METHODS

Adverse events in 72 patients who received 518 instillations were prospectively assessed using a four-class scale based on severity and duration. Urinary leukocytes were counted 3 days after each instillation, using the KOVA-Slide 10 method.

RESULTS

High leukocyturia during BCG treatment (cutoff value 1.65 x 10(5)/mL urine) correlated with recurrence-free status (P = 0.009). The degree of leukocyturia correlated with the severity/duration of adverse events (P <0.0001); the median leukocyturia values associated with class I, II, and III adverse events were 4 x 10(4)/mL, 1.5 x 10(5)/mL, and 3.5 x 10(5)/mL, respectively. No class IV events occurred. The cutoff point indicating treatment cessation for adverse events was leukocyturia of 8.6 x 10(4)/mL.

CONCLUSIONS

These results suggest a link between adverse events and efficacy during BCG maintenance therapy. Leukocyturia appears to correlate with both efficacy and tolerability in this setting. Prospective randomized studies are required to evaluate leukocyturia as a basis on which to adapt the BCG instillation schedule to individual patient susceptibility.

Renal tumor size: comparison between computed tomography and surgical measurements

OBJECTIVE

We studied the agreement between renal tumor size as assessed on computed tomography (CT) before surgery and that measured during histopathological examination on the radical nephrectomy specimen.

METHODS

We retrospectively analyzed the records of 100 consecutive patients treated with radical nephrectomy for a renal tumor. The tumor size was determined in all patients by the largest diameter shown within the month before surgery on contrast-enhanced CT and as measured postoperatively by the pathologist. A possible influence of the clinical and pathological parameters was assessed in a multivariate analysis.

RESULTS

CT estimate and surgical measurement of tumor size were highly correlated (r = 0.9; p<0.001). Median (range) tumor size was 70.0 mm (13-180) and 60.0 mm (10-180) as measured, respectively, on CT and in the specimen, with a significant difference (p = 0.005). Multiple regression did not reveal any significant influence of tumor side, location, type, nuclear grade as well as patient gender, body mass index and radiological center (p>0.3 in all cases). The extent of difference between CT and surgical measurements was significantly influenced by the surgical size of the tumor (p = 0.03): the smaller the tumor, the more the CT overestimated the tumor size. If nephron-sparing surgery had been planned for tumors equal to or less than 40 mm, 24 patients would have been selected following the CT estimate, while 27 patients would have met this criterion on the surgical measurement.

CONCLUSION

Renal tumors were statistically smaller than the estimate from CT, although this was not systematically the case. This should be kept in mind when issuing recommendations on the optimal cutoff size value under which nephron-sparing surgery is considered equivalent to radical nephrectomy.

Familial ureteral duplication and ureterocele: two sisters and their father

We studied a family in which the father and his two daughters had ureteroceles involving the upper half of a duplex system. Our report gives additional evidence for the genetic background of ureteroceles.

[Impact of genital prolapse on the upper urinary tract]

The authors reviewed five cases of genital prolapse affecting the upper urinary tract and causing renal failure.

CLINICAL CASES

Five patients aged 55 to 75 years presented with genital prolapse, which was known by the patient in 3 cases for a period of 2 to 30 year, but left untreated. All cases had induced bilateral dilatation of the uretero-pyelocaliceal cavities with severe obstructive renal failure in 3 cases, moderate renal failure in 2 cases and associated with hypertension in 2 cases. Repair of prolapse, preceded by upper urinary tract diversion by ureteric and bladder catheters in 3 cases or pessary + bladder catheter because of the patient's age in 2 cases, cured or improved renal failure in 4 patients; only one patient had to be treated by dialysis because of the severity of the residual renal failure severity.

DISCUSSION

The frequency (4%) of aetiopathogenic mechanisms (ureteric compression, progressive stretching of the ureter and posterior tilting of the trigone) are analysed. The delayed onset of sudden deterioration and the varying degrees of severity of renal failure demand emergency treatment of stage III prolapse with primary diversion of the upper urinary tract, currently by double J stents, until correction or improvement of renal function, after which surgical repair of the prolapse can be performed according to the usual surgical rules. Intravenous urography is still indicated in this situation. Palliative treatment is only indicated in elderly patients or patients with a high operative risk. The best treatment remains prevention by detection and treatment of prolapse before the development of this fortunately rare complication.

CONCLUSION

This short clinical series emphasizes that undiagnosed prolapse can still be complicated by repercussions on the upper urinary tract with a risk of renal failure.

Polyethylene stent blockage: a porcine model

BACKGROUND

Endoscopic insertion of biliary stents is a useful treatment for obstructive jaundice resulting from unresectable tumors of the pancreas and biliary tree. The main drawback is the recurrence of jaundice due to clogging. The aim of this study was to establish an experimental model of polyethylene stent clogging in large white pigs.

METHODS

A straight polyethylene stent of 5F (group I), 7F (group II) or 10F size (group III) was inserted in the common bile duct. Animals were killed at 2 months, or earlier if physical signs suggesting stent clogging occurred. Chemicophysical analysis of stent deposition combined stereomicroscopy and identification of the contents by means of Fourrier transform infrared spectroscopy. Bacteriologic analyses included identification of aerobic and anaerobic bacteria and measurement of beta-glucuronidase, lecithinase and lipase activities.

RESULTS

Physical signs suggesting stent obstruction or death occurred in 8 of 8 animals in group I, 11 of 12 in group II, and 2 of 8 in group III (p < 0.001). The proportion of mucoprotein in the stent contents tended to fall with increasing stent diameter (mean 82%, 58% and 47% for 5F, 7F and 10F, respectively), whereas wheat starch and calcium bilirubinate content increased with increasing stent diameter (9% and 4%, 18% and 10%, and 29% and 23% for 5F, 7 F, and 10F, respectively), although none of these differences were statistically significant. A variety of bacteria were cultured from the stent deposits, including anaerobic strains. Clostridium species were associated with the highest enzyme activities.

CONCLUSIONS

In this model the major component of early stent deposits was mucoprotein, and numerous aerobic and anaerobic bacteria were isolated. Formation of calcium bilirubinate was a late phenomenon and poorly related to bacterial enzymatic activities.

High-grade inflammation in prostate cancer as a prognostic factor for biochemical recurrence after radical prostatectomy. Pathologist Multi Center Study Group

OBJECTIVES

To assess the prognostic value of prostatic stromal inflammation in surgically treated localized prostate carcinoma for biochemical recurrence-free survival.

METHODS

Stromal prostatic inflammation grading was studied in 161 patients who underwent radical prostatectomy for prostate cancer without involvement of the lymph nodes and who did not receive preoperative or postoperative radiotherapy or hormonal therapy until recurrence occurred. Inflammation was graded as high-grade inflammation if confluence of inflammatory cell infiltrate and/or glandular epithelium disruption associated with interstitial inflammatory infiltrate were present and as low-grade inflammation otherwise. Each specimen was graded separately first in the stroma surrounding nonmalignant glands and second in the stroma surrounding malignant glands. Biochemical recurrence based on serum prostate-specific antigen (PSA) level was defined as two successive PSA measurements greater than 1 ng/mL.

RESULTS

Malignant tissue was significantly less involved in high-grade inflammation than benign adjacent tissue (9.3% and 19.9%, respectively; P <0.01). In a univariate Kaplan-Meier analysis, the 5-year recurrence-free survival rate for patients with high-grade and low-grade classified prostates was 61.0% and 66.7% in benign tissue and 27.0% and 65.3% in malignant tissue, respectively, with a significant difference between grades only in malignant tissue (P <0.02). In a multivariate analysis controlling for Gleason grade, preoperative serum PSA, pathologic stage, and inflammation grade in malignant tissue, the latter factor remained significantly predictive of biochemical recurrence (P = 0.03).

CONCLUSIONS

Patients with high-grade inflammation surrounding malignant glands in radical prostatectomy specimens had significantly more postoperative biochemical recurrence than patients with low-grade inflammation.

Symptom characteristics and the development of tolerance with time in patients with indwelling double-pigtail ureteric stents

OBJECTIVE

To determine the symptoms of and factors predicting the tolerance to double-pigtail ureteric stents, and the development of tolerance with time.

PATIENTS AND METHODS

The study included 39 patients (median age 49.0 years, range 26-74; 24 men and 15 women) who were treated in our department for ureteric obstruction caused by benign conditions, excluding pregnancy and associated open surgery. All patients received a polyether-urethane double-pigtail ureteric stent (7 F, 28 cm long). Tolerance to the procedure was assessed using a questionnaire and a 10-cm linear visual analogue scale (VAS) at 24 h and again one week after placement, and on the day before stent removal.

RESULTS

From the end of the first week to before removal of the stent, fewer patients reported dysuria, haematuria and having recourse to painkillers than during the first week. However, analysis of variance for repeated measures showed no significant difference between the VAS scores for first day, the first week and the day before removal, either overall or stratified by gender (P=0.15). A factorial analysis of variance analysing the VAS score for the first week as a function of gender, age and type of occupation (sedentary or mobile occupation) showed a significant effect only for gender (P=0.005) and gender-age interaction (P=0. 02): VAS scores were higher in men and particularly in younger men.

CONCLUSION

Almost all patients with short-term placement of indwelling double-pigtail ureteric stents have untoward symptoms. Although some symptoms, e.g. dysuria and haematuria, significantly improve with time, the general tolerance remains unchanged. Tolerance in men, and particular in younger men, was significantly poorer.

[Schwannoma and the urinary tract. Concerning a tumor of the obdurator nerve]

Peripheral nerve tumours, called schwannomas, because they are derived from cells of the Schwann sheath, are rare tumours that can involve any part of the body, but are essentially located on the limbs, which represent more than 50% of cases. Schwannomas of the trunk and especially pelvic schwannomas are even rarer. A tumour arising from the obturator nerve is exceptional, but its paravesical location can facilitate the diagnosis, as in this case. The complementary investigations most frequently performed are CT and MRI, although they are unable to define the exact nature of the tumour. Surgery must try to preserve continuity of the nerve, but that is not always possible and does not appear to have any major consequences in this site.

The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography-guided biopsy of the prostate: a prospective randomized placebo-controlled study

OBJECTIVE

To evaluate the effect of the rectal administration of lidocaine gel on the tolerance of systematic sextant transrectal ultrasonography (TRUS)-guided prostatic biopsies.

PATIENTS AND METHODS

From January to September 1997, patients undergoing initial biopsy mapping of the prostate (with six systematic TRUS-guided transrectal biopsies) were randomized using a pre-established randomization list into two groups. In group 1, 15 mL of 2% lidocaine gel (Astra, Södertälje, Sweden) was administered intrarectally 15 min before the biopsies. In group 2 (placebo), 15 mL of trans-sonic hydrophilic gel (Rivadis Laboratory, Thouars, France) was administered transrectally under the same conditions. Patients were randomized and the gel administered by a nurse; neither the patients nor the urologists were aware of which product was administered. At the end of the procedure, patients were asked to score the severity of discomfort of the biopsies, using a self-administered rating scale.

RESULTS

In all, 109 patients were included, in either group 1 (56 patients) or group 2 (53 patients). Slight pain or no pain was experienced by the vast majority of patients in both groups. Moderate to severe pain was experienced in 12.5% of patients in group 1 and 11.3% of patients in group 2. There was no difference in patient tolerance between the groups (P=0.39). Only minor complications occurred and complication rates were not significantly different between the groups.

CONCLUSION

The rectal administration of lidocaine has no impact on the tolerance to prostatic biopsy.

[Theoretical conditions for cancer screening. Example of prostate cancer]

Not all cancers are suitable for screening programmes. The disease must be frequent, serious and able to be diagnosed at a stage at which it is curable and an easily acceptable and very specific screening test must be available. The justification for prostate cancer screening is controversial and this screening cannot be recommended on the basis of current knowledge. In this study, the authors evaluated, in the light of the recent literature, to what degree prostate cancer satisfies the theoretical criteria for cancer screening.

BTA stat and BTA TRAK: A comparative evaluation of urine testing for the diagnosis of transitional cell carcinoma of the bladder

OBJECTIVE

We compared the BTA (bladder tumor antigen) stat test with the BTA TRAK assay in patients highly suspicious of bladder cancer.

METHODS

The BTA stat and the BTA TRAK tests are two immunoassays that detect human complement factor H related protein in urine, employing the same antibody pair. The BTA stat is a qualitative test which can be performed in a consultation setting. The BTA TRAK is a quantitative test that is performed in the laboratory. Consecutive patients highly suspicious of bladder cancer were included in this prospective blinded trial to assess the clinical performances of the two methods.

RESULTS

A total of 81 patients were tested using BTA stat and BTA TRAK before cystoscopy. A tumor was identified in 49 patients. BTA TRAK (38/49 true-positive cases) was more sensitive than BTA stat (32/49) in detecting bladder cancer (p < 0.05). When considering the subgroups of bladder cancer by stage and grade, the difference remained significant for low-grade and low-stage tumors. There was no significant difference between BTA TRAK and BTA stat as regards specificity (20/32 and 23/32 true-negative cases, respectively; p = 0.2).

CONCLUSION

BTA TRAK with a cutoff of 14 U/ml had a significantly higher sensitivity than BTA stat in the detection of low-grade and low-stage bladder cancer.

[New diagnostic tests for urothelial tumors of the bladder]

Urothelial bladder tumours require regular surveillance: cystoscopy combined with urine cytology remains the reference examination. Several tests designed to diagnose bladder tumours have been recently proposed in order to replace cytology and possibly reduce or even replace systematic cystoscopy. These tests are currently being evaluated and their indications have not yet been established. In this article, the authors review the results of recent studies concerning bladder tumour antigen (BTA), fibrin/fibrinogen degradation products (AuraTek FDP) and nuclear matrix protein (NMP-22). These tests are the subject of numerous research studies and have already been approved by the United States Food and Drug Administration. The majority of these studies appear to show that these tests have better diagnostic performances than cytology. However, in the absence of an experimental study validating the possibility of replacing cystoscopy in the surveillance of recurrent bladder tumours by one of these tests, they can only be used as an aid to diagnosis, at the present time.

[Renal cancer and late pancreatic metastases. Apropos of 3 cases and review of the literature]

Renal cell carcinoma is a malignant epithelial tumour which can always give rise to metastases, usually situated in the lungs, bone and liver. In contrast, pancreatic metastases are exceptional and can occur late. The authors report three cases of metachronous pancreatic metastases, 1, 4 and 10 years after nephrectomy. The procedures performed consisted of Whipple procedure, tumour excision and total duodenopancreatectomy. Although rare when isolated to the pancreas, these metastases can justify even audacious pancreatic resection.

[Can the prostatic capsule be preserved during cystectomy for bladder tumors: a study of urethral and prostatic involvement in the cystectomy specimens]

OBJECTIVES

To evaluate the frequency of urethral and prostatic lesions on cystectomy specimens for bladder tumour.

MATERIAL AND METHODS

This retrospective histological study was based on 260 specimens: radical cystectomies performed in 7 operative sites. The prostate and urethra were analysed in 3 planes (upper, middle and lower thirds). The apex was studied separately. Urethral invasion was identified by continuity of the tumour or by the presence of vesical CIS.

RESULTS

Urethral involvement is frequent (30.6% cases) essentially due to contiguous invasion (43/80). CIS is the second pathological association (44 urethral CIS/75 bladder CIS). Prostatic adenocarcinoma was present in 17.8% of cases with a Gleason score > 6 for 30% of lesions.

CONCLUSION

The high frequency of urethral and prostatic involvement does not justify preservation of the prostate during cystectomy. A serial prospective study should define the precise criteria able to minimize the risk of conservative surgery.

Breast conservation and prolonged chemotherapy for locally advanced breast cancer: the University of Michigan experience

PURPOSE

To determine whether breast conservation and prolonged neoadjuvant chemotherapy have efficacy in locally advanced breast cancer (LABC), as measured by survival and rate of breast conservation.

MATERIALS AND METHODS

Eighty-nine patients with stage III disease were enrolled at the University of Michigan (UM) onto a prospective nonrandomized trial. Patients received nine 21-day cycles of neoadjuvant chemohormonal therapy that consisted of doxorubicin 30 mg/m2 and cyclophosphamide 750 mg/m2 intravenously on day 1, conjugated estrogens 0.625 mg orally twice daily on days 6 to 8, methotrexate 40 mg/m2 and fluorouracil 500 mg/m2 intravenously on day 8, and tamoxifen 10 mg orally twice daily on days 9 to 14. Patients with a negative biopsy received radiation only, while those with residual disease underwent mastectomy and postoperative radiotherapy. Eight more cycles of chemohormonal therapy were administered after local-regional therapy.

RESULTS

The clinical response rate to neoadjuvant therapy was 97%, 28% of patients had a complete pathologic response evaluated at biopsy. Five-year overall and disease-free survival probabilities were 54% and 44%, respectively. The median disease-free survival time was 2.4 years. The 5-year actuarial rates of local-regional control with local failure as only first failure were 82% and 78% following radiotherapy, and mastectomy and radiotherapy, respectively (P = .99).

CONCLUSION

Prolonged neoadjuvant chemohormonal therapy and biopsy-driven local therapy have efficacy in LABC, with 28% of patients being candidates for breast conservation and a 5-year overall survival rate of 54%.

Patient tolerance of transrectal ultrasound-guided biopsy of the prostate

OBJECTIVES

To determine the acceptability by patients of ultrasound-guided prostatic biopsy without anaesthesia.

PATIENTS AND METHODS

From January 1995 to January 1996, 81 patients in our department undergoing transrectal ultrasound-guided prostate biopsy were asked to assess the tolerability of the procedure using an immediate post-operative questionnaire including a 10 cm linear visual analogue scale (VAS).

RESULTS

The mean VAS score was 3 (standard error 0.24) and 16% of the patients had a VAS score of > or = 5. Responses to the questionnaire showed that 6% of patients judged that the procedure should have been performed under general anaesthesia, while 19% would not agree to undergo it again without some form of anaesthesia.

CONCLUSIONS

Even when anaesthesia-free, transrectal ultrasound-guided prostatic biopsy was felt to be only mildly uncomfortable by most patients, but 19% judged that it should be accompanied by some form of anaesthesia. Consequently, local anaesthetic techniques to enhance tolerance to this type of intervention without sacrificing the advantages of the current out-patient setting should be reassessed.

Inflammation in benign prostatic hyperplasia: correlation with prostate specific antigen value

PURPOSE

We attempted to identify morphological parameters of benign prostatic hyperplastic inflammation that correlate with pre-biopsy prostate specific antigen (PSA) concentrations.

MATERIALS AND METHODS

Patients undergoing prostate biopsy at our department were prospectively studied between January 1995 and January 1996. preoperative blood and 24-hour urine samples were measured for PSA. Biopsy samples harboring exclusively benign prostatic tissue were graded on a 4-point scale for inflammation (0-no inflammatory cells, 1-scattered inflammatory cell infiltrate, 2-nonconfluent lymphoid nodules and 3-large inflammatory areas with confluence of infiltrate) and aggressiveness (0-no contact between inflammatory cells and glandular epithelium; 1-contact between inflammatory cell infiltrate and glandular epithelium; 2-clear but limited, that is less than 25% of the examined material, glandular epithelium disruption, and 3-glandular epithelium disruption on more than 25% of the examined material).

RESULTS

A total of 66 patients with exclusively benign prostatic tissue on prostate biopsies was analyzed. Difference between inflammation graded groups was not significant when considering serum or urinary PSA. There was a significant correlation between aggressiveness grading and serum PSA (rho = 0.51, p < 0.0001), whereas aggressiveness grading and urinary PSA did not correlate (rho = -0.06, p = 0.6).

CONCLUSIONS

Prostatic subclinical inflammation is not associated with high urinary PSA. Unless associated with glandular epithelial disruption, density of prostatic interstitial inflammatory cell infiltrate is not significantly correlated with serum PSA concentration. We believe that this issue should be considered when interpreting a prostate biopsy.

[Serum and urine prostate-specific antigen ratio: its value in the distinction between prostate cancer and adenoma when serum prostate-specific antigen level is between 4 and 10 ng/ml]

BACKGROUND

In an earlier study, we demonstrated that benign prostatic hyperplasia (BPH) was associated with significantly higher urine levels of prostate-specific antigen (PSA) than in prostate cancer (PC). These early results led to the present study: we assessed, in patients undergoing a prostate biopsy, the clinical value of the PSA serum/urine ratio (PSA S/U) in patients for the differential diagnosis of PC, particularly when the pre-biopsy serum level of PSA lies between 4.0 and 10.0 ng/ml.

METHODS

All patients without an indwelling drain who underwent transrectal echoguided biopsy were prospectively included in this study from November 1994 to December 1995. All serum and urine PSA measurements were done by the same laboratory using a Tandem R kit (Hybritech). Blood and urine samples were obtained during the 24 hour period prior to surgery during which all urethral or rectal manipulation was avoided.

RESULTS

We studied 130 patients with BPH (n = 73) or PC (n = 57). The PSA serum levels and the PSA S/U were significantly different between the BPH and the PC groups. In the subgroup of 50 patients with a serum PSA level in the 4-10 ng/ml range, the difference between the BPH and PC patients was not significantly different except for the PSA S/U ratio. Receiver operating characteristic (ROC) curves showed that the diagnostic power of PSA S/U was greater than serum PSA.

CONCLUSION

These results suggest that the PSA S/U ratio could be useful to distinguish between BPH and PC, particularly when diagnosis is uncertain in patients whose serum PSA is in the 4.0-10.0 ng/ml range.

Serum-to-urinary prostate specific antigen ratio: its impact in distinguishing prostate cancer when serum prostate specific antigen level is 4 to 10 ng./ml

PURPOSE

Benign prostatic hyperplasia (BPH) was shown to be associated with high concentrations of urinary prostate specific antigen (PSA). We investigated the serum-to-urinary PSA ratio in patients undergoing prostate biopsy to assess its efficacy in enhancing serum PSA specificity in the detection of prostate carcinoma.

MATERIALS AND METHODS

From November 1995 through January 1996 consecutive patients undergoing prostate biopsy were prospectively included in the study. Serum and urine PSA levels were measured at our laboratory with the Tandem-R assay. Samples were drawn 24 hours before prostate biopsy and at a distance from prostatic manipulation or ejaculation.

RESULTS

We studied 73 patients with BPH and 57 with prostate cancer. Differences between BPH and prostate cancer were statistically significant considering serum PSA or serum-to-urinary PSA ratios. In the 50 patients with a serum PSA of 4.0 to 10.0 ng./ml. (35 with BPH and 15 with prostate cancer) the differences between prostate cancer and BPH were still significant only when considering serum-to-urinary PSA ratio. Receiver operating characteristic curves showed that serum-to-urinary PSA ratio was a better predictor of prostate cancer than serum PSA.

CONCLUSIONS

Our results suggest that the serum-to-urinary PSA ratio may be useful in distinguishing BPH from prostate cancer, particularly in the diagnostic gray zone of serum PSA between 4.0 and 10.0 ng./ml.

[Orbital metastasis of prostatic cancer. Clinical and therapeutic aspects. Apropos of a case (clinical case)]

A metastasis to the left orbit revealed cancer of the prostate in a 60-year-old man. Such localizations are rare compared with the frequency of bone metastasis in cancer of the prostate. Diagnostic methods are discussed together with the urgent required to save the eye.

Radiographic prognostic criteria for extracorporeal shock-wave lithotripsy: a study of 485 patients

OBJECTIVES

We studied 485 patients treated by extracorporeal shock-wave lithotripsy (ESWL) using an ultrasound electrohydraulic apparatus in an effort to define radiographic criteria for better patient selection for ESWL.

METHODS

Results were assessed according to plain x-ray nephrotomography and ultrasound. The criteria for measuring success (stone free [SF]) excluded all residual fragments. After per-criteria analysis of the results, a multivariate analysis as well as an analysis of stone composition by infrared spectroscopy were performed.

RESULTS

The SF rate was 57.5% (279 of 485). Calculi that were smooth, denser than bone, located in the lower calyx, and larger than 15 mm had less satisfactory results despite a greater number of impulses. A correlation was established between the radiographic appearance of the calculus, its composition, and ESWL results. Rough, less dense calcium oxalate dihydrate yielded satisfactory results (65%), whereas smooth, dense calcium oxalate monohydrate led to less conclusive results (41%). Multivariate analysis demonstrated the predominant influence of radiographic calculus profile on the results: rough, less dense calculi yielded a 79.4% SF rate, whereas smooth, dense calculi yielded a 33.6% SF rate.

CONCLUSIONS

We propose that patients with dense, smooth calculi located in the lower calyx and larger than 15 mm be treated by other techniques, such as percutaneous nephrolithotomy. This would not only increase the ESWL effectiveness rate, but would also reduce the cost of treating kidney stones.

Serum-to-urinary prostate-specific antigen ratio: a potential means of distinguishing benign prostatic hyperplasia from prostate cancer

OBJECTIVE

High concentrations of serum prostate-specific antigen (PSA) may be associated with the presence of benign prostatic hyperplasia or prostatitis. We investigated the serum-to-urinary PSA ratio in patients with or without prostate cancer to assess its efficacy in enhancing serum PSA specificity.

METHODS

Patients presenting abnormal findings in digital rectal examination or documented prostate carcinoma were prospectively included in the study. A control group, with no evidence of prostate disease, hospitalized in the same time interval was included. Serum and urine PSA levels were measured in our laboratory with the Tandem R assay (Hybritech). Samples were drawn twice at 2-month intervals (M1 and M3).

RESULTS

Sixty-eight patients were included in the study divided into 27 cases of benign prostatic hyperplasia, 20 of prostate carcinoma, 10 of prostatitis and 11 patients in the control group. Serum and urine PSA levels were not correlated (r < or = 0.1). There was no significant difference in any group from M1 to M3 as regards urinary PSA (p > or = 0.15). Intergroup comparison showed significantly (p < or = 0.004) high urinary PSA (mean level +/- SEM 28.3 +/- 3.4 micrograms/mmol creatinine) only in the benign prostatic hyperplasia group, mean levels in the prostate carcinoma, prostatitis and control groups being 3.7 +/- 1.1, 11 +/- 2.9 and 5.2 +/- 0.9 micrograms/mmol creatinine, respectively. Differences in urinary PSA levels between the confined prostate carcinoma and benign prostatic hyperplasia groups (p = 0.0008) were further increased when considering the serum-to-urinary PSA ratio (p = 0.0003).

CONCLUSION

Our results suggest that the serum-to-urinary PSA ratio may be useful in distinguishing benign prostatic hyperplasia from prostate cancer.

[Multiple myeloma of the testis]

The testis is a rare site of multiple myeloma. The authors report such a case in a patient with a 7-year history of multiple myeloma. Transinguinal castration was performed. Six months after the operation, the patient did not have any other extramedullary sites, but the disease progressed rapidly with diffuse bone pain and end-stage renal failure. The diagnosis and management are discussed in the light of a review of the literature.

[Experimental study of urinary calculi fragmentation with pulsed laser shockwave, based on their chemical composition]

OBJECTIVES

To attempt to classify the resistance of urinary calculi to shock waves according to the chemical composition of the calculi most frequently treated in clinical practice.

METHOD

Seventy four urinary calculi obtained after surgery were submitted to shock waves produced by an experimental neodyme glass phosphate pulsed laser, at a frequency of 532 nanometres, delivering impulses of 4.8 Joules lasting 25 nanoseconds with a recurrence of 1 second. The calculi (25 homogeneous: 90% of one constituent, 49 heterogeneous: > 45% < 90% of one constituent) had to be fragmented down to 2 mm fragments. The total fragmentation energy (TFE) required was the parameter adopted to classify calculi and to compare the fragmentation of various chemical compositions studied by infrared spectrophotometry. The TFE of 25 homogeneous calculi were compared to a microhardness study performed on calculi with the same chemical composition. The fragmentation thresholds energy (TFE) was used to compare the fragmentation thresholds of each type of calculi. Statistical analysis by ascending multiple regression was performed to classify the various factors likely to influence fragmentation.

RESULTS

Two groups were able to be significantly distinguished according to whether the TFE required to obtain 2 mm fragments was greater than 200 Joules (cystine, weddellite, brushite, uric acid) or less than 200 Joules (weddellite, carbapatite, struvite). Only cystine and whewellite significantly increased the fragmentation threshold. For the 125 homogeneous calculi, the correlation with microhardness demonstrated an inverse relationship between friability and increased microhardness. A crossover between microhardness and friability to shock waves was only observed for whewellite and cystine. For the 49 heterogeneous calculi, this study showed that when weddellite was the predominant component of a stone, the friability tended to increase. Struvite and whewellite significantly facilitated and decreased fragmentation of heterogenous calculi, respectively.

CONCLUSIONS

This study allowed urinary calculi to be classified into three groups: friable (weddellite, carbapatite, struvite), intermediary (brushite, uric acid, whewellite) and resistant (cystine). Although this laser cannot be used clinically, the constants were similar to those of pulsed lasers available in clinical practice and the results of the study corresponded to those already observed empirically by other teams or observed experimentally on a single stone corresponding to each type of chemical composition. The clinical application of this study would be to prospectively compare the results with those observed in clinical lithotripsy.