Incidence of granulomatous prostatitis and acid-fast bacilli after intravesical BCG therapy

Evaluation of incidence, predictive factors and treatment considerations for asymptomatic genitourinary granulomas after intravesical bacillus Calmette-Guérin therapy

INTRODUCTION AND OBJECTIVES

Although the complications of intravesical BCG treatment are well described, asymptomatic genitourinary granulomas after BCG therapy have rarely been reported and management strategy for these conditions remains controversial. The objective of this study is to evaluate the incidence rate of asymptomatic genitourinary granuloma formation mimicking bladder cancer recurrence after intravesical bacillus Calmette-Guérin (BCG) therapy and to identify the diagnostic and treatment strategies according to patient conditions.

PATIENTS AND METHODS

A retrospective review was conducted on 162 patients who underwent intravesical BCG therapy. For patients who developed granulomas, we evaluated the time interval between BCG instillation and the development of granuloma, the presence of acid-fast bacteria on pathology specimens, culture/polymerase chain reaction results, management strategies for the lesions, and clinical outcomes.

RESULTS

Asymptomatic genitourinary masses developed in 14 patients, of whom 5 underwent histological examinations and all were confirmed to have granulomatous inflammation. The affected organs included the kidney, bladder, prostate, and penis. While four of the five patients did not receive treatment for their granulomas, one patient was administered antituberculous medication to prevent worsening of the lesion during the perioperative period of the scheduled cystoprostatectomy. None of the patients experienced worsening or recurrence of granulomatous lesions. Patients who developed asymptomatic masses (n = 14) were significantly younger than those who did not (p = 0.0076) and multivariate analysis also showed that younger age was independently associated with the development of clinically suspicious lesions (p = 0.032); however, none of the parameters were associated with histologically confirmed granuloma formation.

CONCLUSIONS

Genitourinary granulomas mimicking recurrence of carcinoma may develop in nearly 10% of patients after intravesical BCG therapy. Most patients can be managed without potentially toxic antituberculosis therapy.

Prostatitis: A Review

PURPOSE OF REVIEW

Pathologies of the prostate in men are one of the most prevalent clinical conditions today [1]. Specifically, pelvic inflammatory disease such as prostatitis can cause symptoms and syndromes different from urological ones, such as bowel or nervous system manifestations. This has a largely negative impact on the quality of life of patients. Therefore, it is convenient to know and update the information about the therapeutic approach to prostatitis, which is a challenge that involves different medical specialties. The aim of this article is to provide summarized and focused evidence to help in the therapeutic approach of patients with prostatitis. A computer-based search of the PubMed and Cochrane Library databases was used to perform a comprehensive literature review on prostatitis, with special interest in recent findings and latest therapeutic guideline recommendations.

RECENT FINDINGS

Recent discoveries about the epidemiology and clinical classifications of prostatitis seem to incur in an increasingly individualized and directed management, with the aim of covering all the confluent factors in prostatic inflammatory pathology. In addition, the role of new drugs and combination with phytotherapy open up a range of new treatment possibilities, although future randomized studies will be necessary to better understand how to use all treatment modalities. Despite all the knowledge acquired about the pathophysiology of prostate diseases, and due to their interrelation with other pelvic systems and organs, there are still gaps that make it difficult for us to provide an optimal and standardized treatment in many of our patients. Being aware of the influence of all the factors potentially involved in prostate symptoms is crucial for a correct diagnosis and establishing an effective treatment plan.

Imaging Patterns of Bacillus Calmette-Guérin-Related Granulomatous Prostatitis Based on Multiparametric MRI

Objective

To categorize multiparametric MRI features of Bacillus Calmette–Guérin (BCG)-related granulomatous prostatitis (GP) and discover potential manifestations for its differential diagnosis from prostate cancer

Materials and Methods

The cases of BCG-related GP in 24 male (mean age ± standard deviation, 66.0 ± 9.4 years; range, 50–88 years) pathologically confirmed between January 2011 and April 2019 were retrospectively reviewed. All patients underwent intravesical BCG therapy followed by a MRI scan. Additional follow-up MRI scans, including diffusion-weighted imaging (DWI), were performed in 19 patients. The BCG-related GP cases were categorized into three: A, B, or C. The lesions with diffusion restriction and homogeneous enhancement were classified as type A. The lesions with diffusion restriction and a poorly enhancing component were classified as type B. A low signal intensity on high b-value DWI (b = 1000 s/mm²) was considered characteristic of type C. Two radiologists independently interpreted the MRI scans before making a consensus about the types.

Results

The median lesion size was 22 mm with the interquartile range (IQR) of 18–26 mm as measured using the initial MRI scans. The lesion types were A, B, and C in 7, 15, and 2 patients, respectively. Cohen’s kappa value for the inter-reader agreement for the interpretation of the lesion types was 0.837. On the last follow-up MRI scans of 19 patients, the size decreased (median, 5.8 mm; IQR, 3.4–8.5 mm), and the type changed from A or B to C in 11 patients. The lesions resolved in four patients. In five patients who underwent prostatectomy, caseous necrosis on histopathology matched with the non-enhancing components of type B lesions and the entire type C lesions.

Conclusion

BCG-related GP demonstrated three imaging patterns on multiparametric MRI. Contrast-enhanced T1-weighted imaging and DWI may play a role in its differential diagnosis from prostate cancer.

An ambivalent prostate nodule after Bacillus Calmette-Guérin therapy

A 65-year-old patient without specific associated pathology was treated for a high-grade non-invasive papillary urothelial carcinoma by surgery associated with repeated intravesical Bacillus Calmette-Guérin (BCG) instillations. During follow-up, magnetic resonance imaging (MRI) found a clinically indurated prostate nodule with suspected extensive capsular invasion. Prostatic biopsies showed epithelioid and giant-cell granuloma associated with a single focus of adenocarcinoma. Urinary culture test and specific PCR confirmed the involvement of Mycobacterium bovis. The patient was treated first by rifampin, isoniazid and ethambutol and then by rifampin and isoniazid for a total duration of 9 months, with MRI reassessment at various intervals. After BCG therapy, systemic infectious complications but also local complications such as granulomatous disease have been reported, but prostatic abscesses with M. bovis mimicking cancer on MRI are rare. Consequently, we advise specific local urinary and prostate samples to test for mycobacteria (staining, culture, PCR) in order to avoid aggressive high-risk prostatic surgery.

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Bacillus Calmette-Guérin instillations for bladder carcinoma are usually prescribed.

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Infectious complications are rare after instillations and difficult to diagnose.

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This case of prostate nodules after treatment can suggest aggressive prostate cancer.

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A strategy diagnostic based on microbiology and imaging is necessary in our case.

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A trial antibiotic treatment should be considered at the first sign of doubt.

Revisiting an Old Conundrum: A Systematic Review and Meta-Analysis of Intravesical Therapy for Treatment of Urothelial Carcinoma of the Prostate

BACKGROUND

The optimal management of non-invasive (mucosal and/or ductal) urothelial carcinoma of the prostate remains elusive and there is a paucity of data to guide treatment.

OBJECTIVE

Our objective was to systematically review and synthesize treatment responses to conservative management of non-invasive prostatic urothelial carcinoma using intravesical therapy.

METHODS

A systematic literature search using MEDLINE, EMBASE, Cochrane Library, SCOPUS, and Web of Science databases from inception to November 2019 was performed. Risk of bias assessment was performed using the Newcastle-Ottawa scale for non-randomised studies. Pooled estimates of complete response in the bladder and prostate and prostate only were performed using a random effects model. Pre-specified subgroup analyses were generated to assess differences in complete responses for: BCG therapy vs other agents, ductal vs mucosal involvement, CIS vs papillary tumors and TURP vs no TURP.

RESULTS

Nine studies including 175 patients were identified for inclusion in the systematic review and meta-analysis. All were retrospective case series and most evaluated response to BCG therapy. The pooled global complete response rate for intravesical therapy was 60%(95%CI: 0.48, 0.72), and for prostate 88%(95%CI: 0.81, 0.96). Pre-specified analyses did not demonstrate statistically significant differences between subgroups of interest.

CONCLUSIONS

Management of non-invasive prostatic urothelial carcinoma using intravesical therapy yields satisfactory results. Caution should be taken in treating patients with papillary tumors and ductal involvement, as data for these populations is limited. TURP may not improve efficacy, but is required for staging. Current recommendations are based on low quality evidence, and further research is warranted.

Epidemiological study of granulomatous prostatitis in a tertiary hospital: Associated risk factors and relationship with prostate cancer

OBJECTIVE

The primary objective was to estimate the incidence of granulomatous prostatitis (GP) in Son Espases University Hospital, a tertiary care hospital, in Palma de Mallorca (Spain). As secondary objectives, presence of concomitant PCa in the biopsy was analyzed, as well as the history of previous BCG instillations, biopsy origin, urinary symptoms, and cardiovascular risk (CV) factors.

METHODS

A descriptive retrospective study of GP and the aforedescribed variables were carried out from 2010 to 2017.

RESULTS

A total of 3651 histopathological prostate specimens were analyzed, 39 of which were diagnosed with GP (incidence of 1.06%). Lower urinary tract symptoms (LUTS) were present in a 48.7% and previous history of bladder tumor resection (TURBT) was present in 35.9% of the cases. Also, urinary tract infections were equally present. All cases with prior TURBT had intravesical instillations with BCG, although 5 (12.8%) and 4 (10.3%) cases had abnormal rectal examination and elevated PSA levels after instillations, respectively. Finally, in 14 cases (35.9%) there was also a diagnosis of concomitant PCa. The most common CV risk factor in these patients was smoking (79.5%) followed by hypertension (64.8%).

CONCLUSIONS

The estimated incidence of GP in our center (1.06%)g is close to that described by other authors. About 14 cases were diagnosed with PCa (35.9%), a higher value than previously described in the literature, and most of these were found incidentally, especially in cystoprostatectomies. This high percentage of concomitant GP and PCa could be due to a rise in Transrectal Prostate biopsies (TRPB), as in recent years there has been a tendency to increase the use of PSA in routine clinical practice.

Complications of intravesical BCG therapy in non-muscle invasive bladder cancer: our tertiary care centre experience

Background

Urothelial bladder carcinoma accounts for around 3.9% cases of all the male cancers in India. Non-muscle-invasive bladder carcinoma (NMIBC) is predominant group which constitute approximately three fourth of the urothelial bladder cancer. Intravesical BCG immunotherapy is the corner stone of today’s NMIBC management. However, as with any other therapy it has its own complications and its interruption due to these adverse effects is a major cause of suboptimal efficacy. The aim of this study was to assess the complications of intravesical BCG therapy and their management in NMIBC patients.

Methods

This was a retrospective descriptive study conducted between October 2016 and November 2019; a backward review of 149 patients with diagnosis of NMIBC that undergone intravesicle BCG therapy was performed. Patient’s demographical, clinical, diagnostic and procedural data regarding bladder tumour, BCG therapy, its complications and management were collected and analysed.

Results

Total 149 patients were analysed, comprising 116 males and 33 females. The mean age was of 57.2 ± 6.7 years. Total 85.23% were primary and 14.76% were recurrent tumours. Total 96 patients (64.42%) completed the planned course, while 53 (35.57%) interrupted. The reasons for BCG interruption includes adverse effects (15.4%), progression of disease (6.7%), disease refractory to BCG (4.6%) and disease recurrence during BCG (3.3%). Most of the adverse events occurred in first 6 months and most interruptions occurred after the induction period. Cystitis was the most common observed adverse effect seen in 39.6% patients. Frequency, urgency, haematuria were common presentation. Radical cystectomy was the most common (16.10%) further treatment with patients whose treatment was interrupted.

Conclusion

BCG is an indispensable therapy available for NMIBC, but it is associated with array of adverse effects and complications, which are the main reasons for poor compliance to BCG therapy. Although BCG-related complications can affect any organ in the body, potentially life-threatening systemic BCG-related infections are encountered in only < 5% of patients. There are some difficulties in diagnosis of the BCG complications because acid-fast staining, culture and PCR test are not always positive; tissue biopsies should be indicated sometimes to evaluate histopathology and presence of M. bovis. A persistently monitored multidisciplinary approach with high index of suspicion and prompt anti-TB therapy can help to derive the maximum benefits while keeping the complications at check.

Analysis of risk factors for post-bacillus Calmette-Guerin-induced prostatitis in patients with non-muscle invasive bladder cancer

The objective of this study was to evaluate risk factors for bacillus Calmette–Guerin-induced prostatitis in patients with non-muscle invasive bladder cancer following bacillus Calmette–Guerin therapy. Clinical findings from patients with non-muscle invasive bladder cancer who underwent multi-parametric magnetic resonance imaging before transurethral resection of bladder tumor and post-bacillus Calmette–Guerin therapy from March 2004 to August 2018 were evaluated. The population was grouped into patients with or without newly developed lesions on multi-parametric magnetic resonance imaging performed 3 months after bacillus Calmette–Guerin instillation. Patients with prostate-specific antigen levels ≥ 4 ng/mL or prostate cancer were excluded. Univariable and multivariable analyses were performed to determine the predictors of prostate lesions in patients with prior bacillus Calmette–Guerin exposure. Post bacillus Calmette–Guerin-induced prostatitis was found in 50 of the 194 patients (25.8%). No significant differences were observed between the groups except for prostate volumes (33.8 mL vs. 30.8 mL, P = 0.012) and body mass index (25.2 kg/m² vs. 24.1 kg/m², P = 0.044). After bacillus Calmette–Guerin exposure, no significant differences in prostate-specific antigen levels, international prostate symptom scores, or post-voiding residual volume were noted. Multivariable regression analysis showed that body mass index (odds ratio, OR = 1.115, P = 0.038) and prostate volume (OR = 3.080, P = 0.012) were significant predictors of post-bacillus Calmette–Guerin prostate lesions. Body mass index and prostate volume may be clinical predictors of prostate lesions after bacillus Calmette–Guerin exposure. Awareness of potential risk factors for this entity should contribute to the clinical decision-making process for patients following bacillus Calmette–Guerin therapy.

Granulomatous prostatitis mimicking prostate cancer in a patient with psoriatic arthritis: a case report

Granulomatous prostatitis (GP) is an unusual and benign inflammatory condition of the prostate, where autoimmunity has been recognized as a key factor in the pathogenesis of GP in a subset of patients. Clinically, GP poses diagnostic challenges as it may strongly mimic prostate cancer from a clinical, biochemical and radiological point of view. The occurrence of GP in patients suffering from psoriasis, a systemic autoimmune disease, has never been investigated. We describe the case of GP in a patient with psoriatic arthritis presenting with an increased prostate specific antigen level, and evidence of a nodular lesion visualized by prostate multiparametric magnetic resonance imaging, which was highly suspicious for aggressive prostate cancer.

Granulomatous prostatitis is an uncommon inflammatory condition of the prostate that can mimic prostate cancer due to increased prostate specific antigen levels and suspect findings from both digital rectal exploration and prostate magnetic resonance imaging. This condition is considered an autoimmune disorder in many cases. We report the association between granulomatous prostatitis and psoriasis, another autoimmune disease.

Iatrogenic Disease of the Genitourinary Tract

Iatrogenic disease is defined as illness caused by diagnostic procedures or treatment given by health care professionals. More recently described treatment complications involving the genitourinary tract include newly recognized variants of renal carcinoma in the setting of dialysis/end-stage renal disease, treatment effect in genitourinary carcinomas, and medical renal disease caused by drug therapies, including immunotherapy. The objective of this review is to cover iatrogenic inflammatory diseases, pseudotumors and tumors of the kidney, bladder, prostate, testis and paratestis of most interest to surgical pathologists. For this reason, disease caused by the following will not be covered: iatrogenic glomerulonephritis, self-inflicted injury including the introduction of foreign bodies, surgical error, drugs of abuse and herbal medications, and iatrogenic disease in the transplant setting including ischemia/reperfusion injury. Emphasis is placed upon commonly encountered diseases in order to ensure that the review is of utility to practicing pathologists. The clinical context, pathophysiology and histopathology of each disease entity are covered.

The distribution of BCG prostatitis: A clue for pathogenetic processes?

BACKGROUND

We observed in cystoprostatectomy specimens that Bacillus Calmette-Guérin (BCG) granulomatous prostatitis tended preferentially to affect the peripheral zone (PZ) and aimed to study the matter, postulating that assessment of its distribution might contribute to understanding pathogenetic processes.

METHODS

Entire prostate glands from 27 men (47-83 years; mean = 69 years), who had previously received intravesical BCG therapy for non-muscle-invasive urothelial carcinoma of the bladder, were studied as whole-mount sections to determine the anatomical distribution and histopathological characteristics of BCG prostatitis.

RESULTS

Twenty-two (81.5%) showed BCG-type granulomatous inflammation. It often radiated from close to the prostatic urethra toward to the gland periphery as a wedge-shaped area related to one or more duct systems. Twenty-one of these prostate glands (95.5%) showed predominantly or exclusively PZ involvement. Eighteen (81.8%) involved only the PZ, while three cases (13.6%) also showed involvement of the transitional zone (TZ). One case (4.5%) involved only the TZ. No granulomas were seen in the central zone or anterior fibromuscular septum.

CONCLUSIONS

Our observations imply the microanatomical arrangement of prostatic ducts is a factor in the pathogenesis of BCG prostatitis. PZ ducts enter the urethra at less obtuse angles than those from other zones and are likely to be more prone to urine reflux and damage from suspended BCG. We speculate that prostatic duct microanatomy could also play a role in the pathogenesis of other prostatic diseases, including conventional prostatitis and adenocarcinoma.

Treatment experience for incidentally diagnosed asymptomatic prostate tuberculosis in a patient with history of BCG intravesical therapy

Intravesical BCG therapy after transurethral resection of bladder tumor (TURB) is considered the most effective treatment for prophylaxis against the recurrence of high risk non-muscle invasive bladder cancer, and generally well tolerated and infectious complication are rare. We reported a case of granulomatous prostatitis is a patient who had undergone intravesical BCG therapy due to non-invasive superficial urothelial carcinoma of bladder. This patient was diagnosed by prostate biopsy because of PSA elevation without any other voiding symptoms and abnormal abscess pocket in transrectal ultrasonography.

Multi-parametric MRI findings of granulomatous prostatitis developing after intravesical bacillus calmette-guérin therapy

PURPOSE

To evaluate the multi-parametric MRI (mpMRI) findings in patients with biopsy-proven granulomatous prostatitis and prior Bacillus Calmette-Guérin (BCG) exposure.

MATERIALS AND METHODS

MRI was performed in six patients with pathologically proven granulomatous prostatitis and a prior history of bladder cancer treated with intravesical BCG therapy. Multi-parametric prostate MRI images were recorded on a GE 750W or Philips Achieva 3.0 Tesla MRI scanner with high-resolution, small-field-of-view imaging consisting of axial T2, axial T1, coronal T2, sagittal T2, axial multiple b-value diffusion (multiple values up to 1200 or 1400), and dynamic contrast-enhanced 3D axial T1 with fat suppression sequence.

RESULTS

Two different patterns of MR findings were observed. Five of the six patients had a low mean ADC value <1000 (decreased signal on ADC map images) and isointense signal on high-b-value imaging (b = 1200 or 1400), consistent with nonspecific granulomatous prostatitis. The other pattern seen in one of the six patients was decreased signal on the ADC map images with increased signal on the high-b-value sequence, revealing true restricted diffusion indistinguishable from aggressive prostate cancer. This patient had biopsy-confirmed acute BCG prostatitis.

CONCLUSIONS

Our study suggests that patients with known BCG exposure and PI-RADS v2 scores ≤3, showing similar mpMRI findings as demonstrated, may not require prostate biopsy.

Natural course of asymptomatic abnormal prostate findings incidentally detected by CT after intravesical BCG therapy

BACKGROUND

Detailed information is not currently available on the incidence, natural course, and management of asymptomatic abnormal prostate findings incidentally detected by radiologic evaluations after BCG therapy for non-muscle-invasive bladder cancer patients.

METHODS

We identified 38 patients who were evaluated by contrast-enhanced CT scans before TUR-BT and after BCG therapy between 2006 and 2012. We evaluated the clinical courses of patients with abnormal radiologic findings of the prostate gland after BCG therapy.

RESULTS

Abnormal findings on CT scans were found in the prostate glands of 11 of the 38 patients examined (28.9%), none of whom exhibited any sign or symptom associated with prostatitis. Abnormal findings included a low attenuation area (n = 6, 15.8%), contrast enhancement (n = 3, 7.9%), and a low attenuation area and contrast enhancement in the prostate gland (n = 2, 5.3%). During the follow-up, abnormal prostate findings disappeared spontaneously in most cases without any anti-bacterial or anti-tuberculous drug treatments. No significant differences were observed in patient clinical backgrounds, with the exception of post-BCG prostate volumes, between patients with and without abnormal CT findings. Furthermore, no significant differences were noted in the incidence of the adverse effects of BCG therapy, tumor recurrence rates, or progression rates between patients with and without abnormal CT findings of the prostate gland after BCG therapy.

CONCLUSIONS

Asymptomatic abnormal prostate findings incidentally detected by CT after BCG therapy are not rare, and these disappear over time during the follow-up period without any treatment.

Granulomatous prostatitis after intravesical immunotherapy mimicking prostate cancer

Intravesical immunotherapy with attenuated strains of Mycobacterium bovis is a widely used therapeutic option in patients with non-muscle-invasive transitional cell carcinoma of the bladder. A rare complication of intravesical therapy with the Bacillus Calmette-Guérin vaccine is granulomatous prostatitis, which due to increasing levels of prostate-specific antigen and abnormalities found in transrectal examination of the prostate may suggest concomitant prostate cancer. A case of extensive granulomatous prostatitis in a 61-year-old patient which occurred after the first course of a well-tolerated Bacillus Calmette-Guérin therapy is presented. Due to abnormalities found in rectal examination and an abnormal transrectal ultrasound image of the prostate with extensive infiltration mimicking neoplastic hyperplasia a core biopsy of the prostate was performed. Histopathological examination revealed inflammatory infiltration sites of tuberculosis origin.

Granulomatous Prostatitis After Intravesical Bacillus Calmette-Guérin Instillation Therapy: A Potential Cause of Incidental F-18 FDG Uptake in the Prostate Gland on F-18 FDG PET/CT in Patients with Bladder Cancer

PURPOSE

This study aimed to evaluate the possibility that Bacillus Calmette-Guérin (BCG)-induced granulomatous prostatitis can be a potential cause of benign F-18 FDG uptake.

METHODS

A total of 395 bladder cancer patients who underwent F-18 FDG PET/CT (PET/CT) were retrospectively evaluated. Patients were divided into two groups according to BCG therapy status. Elapsed time after BCG therapy, serum PSA level, results of prostate biopsy, and the SUVmax and uptake pattern in the prostate gland were reviewed. For patients who underwent follow-up PET/CT, the changes in SUVmax were calculated.

RESULTS

While 35 % of patients showed prostate uptake in the BCG therapy group, only 1 % showed prostate uptake in the non-BCG therapy group (p < 0.001). Among 49 patients with FDG-avid prostate lesions, none had suspected malignancy during the follow-up period (median: 16 months). Five patients revealed granulomatous prostatitis on biopsy. The incidence of FDG-avid prostate lesions was significantly higher if the elapsed time after BCG therapy was less than 1 year compared to more than 1 year (p < 0.001). Serum PSA was normal in 88 % of patients. All patients with incidental F-18 FDG uptake in the prostate gland showed focal or multifocal prostate uptake, and median SUVmax was 4.7. In 16 patients who underwent follow-up PET/CT, SUVmax was decreased in 14 patients (88 %) without treatment, and no patients demonstrated further increased prostate uptake (p < 0.001).

CONCLUSIONS

BCG-induced granulomatous prostatitis can be a potential cause of benign F-18 FDG uptake, especially in those with a history of bladder cancer treated with BCG. In BCG-induced granulomatous prostatitis, focal or multifocal prostate uptake is frequently seen within 1 year after BCG therapy, and the intensity of prostate uptake is decreased on the follow-up PET/CT without any treatment.

Granulomatous prostatitis diagnosed during intravesical BCG treatment

The histopathological report of the biopsy material retrieved from hyperemic areas of the bladder during control cystoscopy of a 70-year-old man who had a bladder cancer diagnosis three years previously, indicated the presence of a carcinoma in situ (CIS). Intravesical immunotherapy treatment was initiated. After severe symptoms of dysuria emerging during intravesical immunotherapy with BCG, the immunotherapy treatment dosage was lowered. His treatment was then discontinued due to the progression of symptoms. A biopsy was performed due to higher prostate spesific antigen (PSA) and digital rectal examination abnormalities which indicated granulomatous prostatitis. An antituberculosis treatment was initiated because the PPD test result was 25 mm and the QuantiFERON test was positive. After one month, the patient's PSA levels were reduced, and his clinical status improved. The symptoms of severe dysuria, sterile pyuria, abnormal digital rectal examination findings and high PSA levels during intravesical BCG treatment should remind us diagnosis of granulomatous prostatitis. It should not be forgotten that diagnosis of granulomatous prostatitis was established histopathologically, and the patient benefited from medical treatment.

Bacillus Calmette-Guérin therapy-associated granulomatous prostatitis mimicking prostate cancer on MRI: A case report and literature review

Granulomatous prostatitis following bacillus Calmette-Guérin (BCG) immunotherapy is a well-known pathological entity, developing following initiation of BCG therapy as a prophylactic measure against the recurrence of non-muscle invasive bladder cancer. In addition, there are certain imaging similarities between granulomatous prostatitis and prostate cancer, including hypoechoic area on transrectal ultrasonography and low T2 signal intensity in some prostate areas on magnetic resonance imaging (MRI). This is the report of a case exhibiting a perfect imaging cross-match between granulomatous prostatitis and potential prostate cancer on repeated MRI exams, adding two supplementary aspects to the already known similarities, namely progressive restricted diffusion and increased contrast enhancement, which are specific to prostate cancer.

The conundrum of prostatic urethral involvement

The presence and depth of urothelial cancer involvement in the prostatic urethra can significantly affect the management of a patient with non-muscle invasive bladder cancer. This article presents an overview of the incidence, diagnosis, management, and follow-up of urothelial cancer.

Nonneoplastic lesions of the prostate and bladder

CONTEXT

Specimens from the prostate and bladder are commonly encountered by the general surgical pathologist. Emphasis is usually placed on neoplasms of the bladder and prostate, particularly if malignant, owing to their therapeutic consequences. A good command of benign lesions occurring in the bladder and prostate, and knowledge of their preneoplastic potential will help pathologists confidently diagnose malignancy versus its benign mimickers and guide the urologists in choosing the appropriate therapy and follow-up for the patient.

OBJECTIVE

To present a mixture of benign entities, and discuss their histologic and clinical characteristics, hoping to provide a practical review for the general surgical pathologist.

DATA SOURCES

An extensive review of the literature on the entities discussed was performed.

CONCLUSIONS

A wide variety of benign entities are present in the prostate and bladder. Benign lesions in the prostate can be age related, such as prostatic atrophy and benign prostatic hyperplasia; transition zone associated, such as basal cell hyperplasia, adenosis, and sclerosing adenosis; or prostatic urethra associated. Benign lesions of the bladder encompass a wide variety of reactive changes that can occur in the urothelium, as well as hyperplastic lesions or reactive proliferations that could be misdiagnosed as malignant. The bladder responds to chronic irritation through several reactive/metaplastic lesions such as cystitis cystica/glandularis, keratinizing squamous metaplasia, or nephrogenic metaplasia. The urothelium can also give rise to hyperplastic/proliferative lesions, in particular von Brunn nest hyperplasia, papillary polypoid cystitis, and pseudocarcinomatous proliferation, which should be distinguished from malignant processes. Ectopic tissue, such as prostatic or mullerian, can also be seen.

Late bacille Calmette-Guérin infection with a large focal urinary bladder ulceration as a complication of bladder cancer treatment

OBJECTIVE

• To report a late bacille Calmette-Guérin (BCG) complication previously not described in the literature.

PATIENTS AND METHODS

• We reviewed our database with 858 patients treated with BCG from 1986 to 2008 and identified 13 male patients (1.8% of all male patients) who had a large tuberculous-like bladder ulcer.

RESULTS

• All patients had high-grade tumours and seven had tumours invading lamina propria before BCG treatment. A solitary ulceration or inflammatory lesion, 10-50 mm in diameter, was seen at routine follow-up cystoscopy 2-34 months (median 8 months) after the first instillation. Significantly more patients had been treated with BCG-RIVM than with BCG-Tice (10/320 vs. three of 454, P < 0.01). BCG was cultured from urine 3-34 months (median 14 months) after the last instillation. • So far, eight patients have been successfully treated with rifampicin and isoniazid. Nine patients are still tumour-free 15-66 months (median 44 months) after the last transurethral resection before BCG treatment. • Another three patients had one to two non-invasive recurrences. One patient had an invasive recurrence and underwent cystectomy. The present study is limited by biases associated with its retrospective design.

CONCLUSIONS

• This is the first report on persisting BCG infections with large inflammatory lesions in the bladder. Treatment is effective and the oncological outcome is good. • Mycobacterial cultures of the urine should be performed in BCG-patients with unclear inflammatory lesions in the bladder since a delayed diagnosis of a persistent BCG infection could result in a permanently reduced bladder capacity. • Large studies are warranted to study differences in efficacy and side-effects between different BCG strains.

Dilemmas in the treatment of urothelial cancers of the prostate

OBJECTIVES

The objective of this paper is to examine the contemporary incidence, diagnosis, and treatment of prostatic urothelial carcinoma and make recommendations on the current dilemmas of treating urothelial cancer of the prostate.

METHODS

A review of English-language literature from 1990 to the present was performed utilizing the U.S. National Library of Medicine's Pub Med database. Keywords used were urothelial cell carcinoma, prostatic urethral involvement, prostatic duct/acini involvement, carcinoma in situ. Bibliographies of reviewed articles were also searched.

RESULTS

Transitional cell carcinoma of the bladder with involvement of the prostate has been reported in multiple studies with an incidence between 12% and 48%. Stromal invasion of the prostate has a reported incidence between 7% and 17%. The incidence of primary transitional cell carcinoma of the prostate has been estimated at 1% to 4% of prostatic malignancies. Degree and depth of prostatic invasion has prognostic significance with 5-year survival rates being 100% for those with urethral mucosal involvement, 50% with ductal/acinar involvement, and 40% with prostatic stromal invasion. The actual anatomic path that urothelial carcinoma invasion occurs also has prognostic significance. Those with contiguous malignant involvement had a 7% 5-year survival rate compared with those with noncontiguous involvement and a 46% 5-year survival rate.

CONCLUSIONS

Prostatic urothelial carcinoma is often under appreciated and not well understood. Malignant involvement of different anatomic locations of the prostate (i.e., mucosa, ducts, acini, and stroma) influence not only diagnosis but treatment of disease. Although debate exists regarding optimal therapy for mucosal involvement, if the prostatic stroma is involved, radical cystoprostatectomy is the treatment of choice.

Urothelial Carcinoma of the Prostate

This study was conducted to explore the diagnosis and management of urothelial carcinoma of the prostate in superficial disease and carcinoma in situ, stromal invasion, primary urothelial carcinoma, and urethral recurrence after radical surgery. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) reviewed the diagnosis and management of urothelial carcinoma of the bladder. English-language literature about urothelial carcinoma of the prostate was identified and reviewed. Evidence-based recommendations for the diagnosis and management of urothelial carcinoma were made. Many recommendations were level 3 or 4 citations involving the diagnosis and management of superficial urothelial carcinoma; a few were level 2 citations. Level 1 citations related only to chemotherapy and radiotherapy in patients with stromal invasion, although these were not related specifically to invasive prostatic involvement. More than 130 reviewed citations are summarized in this review. Published reports on the diagnosis and treatment of superficial urothelial disease of the prostate primarily consist of short case series from individual centers. Prospective and multicenter trials are needed to identify the real incidence and the best management of these patients. In invasive disease of the prostate, the only large series were designed to investigate invasive bladder cancer.

Superficial transitional cell carcinoma: bacillus Calmette-Guérin (BCG) and other intravesical agents

Adjuvant immuno- and/or chemotherapy intravesically has become a standard at least for patients with intermediate or high risk for recurrence. Whereas in the past cystectomy was a first-line therapy for patients with carcinoma in situ or high-grade T1 bladder tumor, radical surgery is today reserved for non-BCG responders or early recurrent disease.

Epididymo-orchitis caused by intravesically instillated bacillus Calmette-Guérin: Genetically proven using a multiplex polymerase chain reaction method

The intravesical instillation of bacillus Calmette-Guérin (BCG) is a standard therapy for superficial bladder carcinoma. Tuberculosis-like inflammation in the genitourinary tract is a serious complication of BCG. It can occur after a long interval from the cessation of the intravesical BCG therapy. If inflammation occurs, it is necessary to test whether the BCG strain has caused it or another mycobacterium species has. However, there has never been a report that proves BCG causes the inflammation, because BCG is difficult to differentiate from other strains of Mycobacterium bovis and other members of the Mycobacterium tuberculosis complex by conventional tests, including regular polymerase chain reaction (PCR). We first present a case of epididymo-orchitis, which developed 31 months after the cessation of BCG therapy, detected using a multiplex PCR method as having been caused by BCG. Our report illustrates the efficacy of this method to detect the responsible microbe that is thought to be transmitted from the instillated BCG strain.

Tubercular prostatic abscess as a complication of intravesical bacillus Calmette-Guerin immunotherapy

We report a case of tubercular prostatic abscess in a patient who had undergone intravesical bacillus Calmette-Guérin immunotherapy for bladder carcinoma in situ. The abscess required surgical drainage and antituberculous treatment.

Nonspecific granulomatous prostatitis with calculous ductal ectasia and extensive Paneth cell-like epithelial metaplasia. Case report

We present a case of nonspecific granulomatous prostatitis in combination with calculous ductal ectasia and extensive epithelial Paneth cell-like metaplasia in a TURP-specimen. Our report highlights the importance of calculous ductal obstruction and stasis of secretions in the etiopathogenesis of this type of prostatitis. The observed extensive Paneth cell-like metaplastic change in adjacent epithelial cells most likely represents a phenotypic adaptive mechanism directed against foreign antigens and nondegradable lipids in the stagnant intraluminal debris.

Consensus development of a histopathological classification system for chronic prostatic inflammation

OBJECTIVE

To develop a standardized histopathological classification system for chronic prostatitis (standardized description of prostatic inflammatory infiltrates) based on a literature review, extensive prospective evaluations in two recognized prostatitis research centres and widespread consensus of international urological centres identified as having major expertise or interest in chronic prostatitis.

METHODS

Relevant articles for review were identified by a Medline search undertaken by the Cochrane Review Group in Prostate Diseases and Urologic Malignancies, and cross-checking bibliographies of retrieved studies, reviews, book chapters and abstracts of the American Urological Association and International Prostatitis Collaborative Network Annual Meetings. Initial drafts were based on classification systems independently developed by the Prostatitis Research Centers at Queen's University in Canada and University of Washington in the USA. A collaborative draft was distributed to 20 urological/pathological clinical centres who participated in the North American Chronic Prostatitis Collaborative Research Network and First International Prostatitis Collaborative Network. A consensus classification system was then distributed to the participating panel for acceptance.

RESULTS

The literature review identified a reasonably consistent description of inflammatory infiltrate locations and patterns that were further incorporated into the draft based on the Queen's University and University of Washington proposals. Eighteen (90%) of the identified Prostatitis Centers participated in the revision of the draft and the final consensus process. The final consensus document classifies prostatic inflammation according to its extent and grade/severity in each tissue compartment (location). Conclusion The consensus of the expert panel was that this classification system can be used in the evaluation of prostatic inflammation in prostate biopsies, transurethral resected prostate chips or prostatectomy specimens. A standardized accepted framework to describe histopathological prostate inflammation will prove useful in evaluating prostate disease.

Prostatitis

The laboratory diagnosis of acute bacterial prostatitis is straightforward and easily accomplished in clinical laboratories. Chronic bacterial prostatitis, and especially chronic idiopathic prostatitis (most often referred to as abacterial prostatitis), presents a real challenge to the clinician and clinical microbiologist. Clinically, the diagnosis of chronic idiopathic prostatitis is differentiated from that of acute prostatitis by a lack of prostatic inflammation and no "significant" (controversial) leukocytes or bacteria in the expressed prostatic secretions. Despite these diagnostic criteria, the etiology of chronic idiopathic prostatitis is unknown. While this review covers the entire spectrum of microbially caused acute prostatitis (including common and uncommon bacteria, viruses, fungi, and parasites) and microbially associated chronic prostatitis, a special focus has been given to chronic idiopathic prostatitis. The idiopathic syndrome is commonly diagnosed in men but is poorly treated. Recent data convincingly suggests a possible bacterial etiology for the condition. Provocative molecular studies have been published reporting the presence of 16S rRNA bacterial sequences in prostate biopsy tissue that is negative for ordinary bacteria by routine culture in men with chronic idiopathic prostatitis. Additionally, special culture methods have indicated that difficult-to-culture coryneforms and coagulase-negative staphylococci are present in expressed prostatic secretions found to be negative by routine culture techniques. Treatment failures are not uncommon in chronic prostatitis. Literature reports suggest that antimicrobial treatment failures in chronic idiopathic prostatitis caused by organisms producing extracellular slime might result from the virulent properties of coagulase-negative staphylococci or other bacteria. While it is difficult to definitively extrapolate from animal models, antibiotic pharmokinetic studies with a murine model have suggested that treatment failures in chronic prostatitis are probably a result of the local microenvironment surrounding the persistent focal and well-protected small bacterial biofilms buried within the prostate gland. These conclusions support the molecular and culture data implicating bacteria as a cause of chronic idiopathic prostatitis.