Assessing the risk of unsuspected prostate cancer in patients with benign prostatic hypertrophy: a 13-year retrospective study of the incidence and natural history of T1a-T1b prostate cancers

Prevalence and potential predictors of incidental prostate Cancer in patients undergoing surgery for Benign Prostatic obstruction: a retrospective study in the MRI era

PURPOSE

Despite advancements in prostate multiparametric magnetic resonance imaging (mpMRI) and fusion biopsy (FB), the management of incidental prostate cancer (IPCa) after surgery for benign prostatic obstruction (BPO) remains unclear. The aim of this retrospective study is to determine the prevalence of IPCa in our cohort and identify potential predictors for its occurrence.

METHODS

We enrolled patients underwent TURP or simple prostatectomy for BPO at our high-volume center between January 2020-December 2022. Data on age, pre-operative total PSA (tPSA) and PSA density (PSAd) levels, prostate volume, previous MRI, biopsies, specimen weight, rates of positive tissue slices, ISUP score and three-month tPSA were collected.

RESULTS

Of 454 patients with negative digital rectal examination who underwent BPO surgery, 74 patients (16.3%) were found to have IPCa. Of these, 33 patients (44.6%) had undergone previous mpMRI. Among the patients who had mpMRI, 23 had negative mpMRI results for suspected prostate cancer, while 10 had positive mpMRI findings (PIRADS ≥ 3) but no evidence of tumor upon FB. KW analysis indicates that PSAd was statistically associated with higher ISUP score, while at univariable regression analysis negative mpMRI (p = 0.03) was the only potential predictor for IPCa.

CONCLUSIONS

Among the ISUP groups, PSAd showed a correlation with the tumor, while negative mpMRI was protective against clinically significant PCa. In the era of mpMRI and FB, the IPCa rates found at our center is higher than reported in existing literature and if it were confirmed with further studies, maybe there is a need for expansion in urology guidelines.

Current Trends in Incidence and Management of T1a and T1b Prostate Cancer

Prostate cancer (PCa) identified incidentally (iPCa) after surgical treatment for symptomatic benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is considered low risk by the most current guidelines. Management protocols for iPCa are conservative and are identical to other prostate cancers classified as having favorable prognoses. The objectives of this paper are to discuss the incidence of iPCa stratified by BPH procedure, to highlight predictors of cancer progression, and to propose potential modifications to mainstream guidelines for the optimal management of iPCa. The correlation between the rate of iPCa detection and the method of BPH surgery is not clearly defined. Old age, small prostate volume, and high pre-operative prostate-specific antigen (PSA) are associated with an increased likelihood of detecting iPCa. PSA and tumor grade are strong predictors of cancer progression and can be used along with magnetic resonance imaging (MRI) and potential confirmatory biopsies to determine disease management. In instances that iPCa requires treatment, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy all have oncologic benefits but may be associated with increased risk after the BPH surgery. It is advised that patients with low to favorable intermediate-risk prostate cancer undergo post-operative PSA measurement and prostate MRI imaging before electing to choose between observation, surveillance without confirmatory biopsy, immediate confirmatory biopsy, or active treatment. Subdividing the binary T1a/b cancer staging into more categories with ranging percentages of malignant tissue would be a helpful first step in tailoring the management of iPCa.

Natural history of incidentally diagnosed prostate cancer after holmium laser enucleation of the prostate

OBJECTIVES

There is no consensus on the management plan for incidental prostate cancer (IPCa) after holmium laser enucleation of the prostate (HoLEP). This study aims to investigate the natural course of this disease and suggest appropriate treatment in real clinical practice.

METHODS

The medical records of a prospective cohort of patients with LUTS/BPH who underwent HoLEP between July 2008 and December 2020 at Seoul National University Hospital were retrospectively reviewed. Patients who underwent HoLEP for palliative purpose of prostate cancer control were excluded. The natural history of IPCa was assessed by the clinician in a descriptive manner for each treatment option.

RESULTS

Among 2630 patients, 141 (5.4%) were diagnosed with IPCa after HoLEP. Pathologic T stage and magnetic resonance imaging results were highly associated with the physician's primary treatment decision-making for IPCa. Active surveillance (AS) was performed in 80% of patients, of whom 90% underwent follow-up without intervention, while the remaining 10% underwent deferred active treatment with a median follow-up of 46.3 months due to International Society of Urological Pathology grade group upgrading or increasing core involvement percentage. Meanwhile, 20% of patients underwent immediate active treatment. With a median follow-up period of 88.3 months after treatment, only one of 25 patients had biochemical recurrence.

CONCLUSIONS

The incidence of IPCa after HoLEP was 5.4%, and among these, approximately 20% proceeded with immediate definitive therapy and an additional 6% ultimately received definitive therapy within a median of 4 years of AS but showed excellent oncological outcomes.

Management about intravesical histological transformation of prostatic mucinous carcinoma after radical prostatectomy: A case report

BACKGROUND

Prostatic mucinous carcinoma (MC) and prostatic signet ring cell carcinoma are two variants of prostate cancer. MC has a higher overall survival time among all variants, while signet ring cell carcinoma is associated with lower survival time relative to other carcinomas. Only a small proportion of prostatic MC may contain signet ring cells. Over the last several decades there were only 12 patients that were documented in two studies.

CASE SUMMARY

We report on a 64-year-old man who was diagnosed with prostatic MC after he received a robotic-assisted laparoscopic radical prostatectomy in the West China Hospital. After robotic-assisted laparoscopic radical prostatectomy, the patient underwent three successive transurethral resections of bladder tumors. Pathological examination of the first transurethral resection of bladder tumors specimen indicated that the neoplasm was prostatic MC that had metastasized to the urinary bladder. The subsequent two transurethral resections of bladder tumors indicated the presence of prostatic mucinous carcinoma with signet ring cells.

CONCLUSION

This case report aimed to share the management experience, raise awareness, and highlight the importance of multidisciplinary cooperation of prostatic mucinous carcinoma with signet ring cells.

Incidental prostate cancer after holmium laser enucleation of the prostate: incidence and predictive factors for clinical progression

OBJECTIVES

To describe the incidental prostate cancer (iPCa) rate and identify predictive factors for PCa progression after holmium laser enucleation of the prostate (HoLEP).

METHODS

A retrospective review of all iPCa cases diagnosed after HoLEP procedures between April 2012 and May 2020 was conducted. iPCa was defined as a symptom-free cancer diagnosed after HoLEP in patients without any diagnosis or suspicion of PCa before surgical treatment. PCa progression was suspected by rise in PSA from baseline after HoLEP and confirmed by progressive disease detected on transrectal needle biopsy or by the appearance of metastatic disease. Univariate and multivariate logistic regression were used to identify predictive factors for cancer progression.

RESULTS

The iPCa rate in our cohort was 10.7% (n = 134). Among patients with iPCa, 25 (18.6%) progressed with a mean follow-up of 32 months. Regarding predictive factors, post-operative PSA (OR 2.35, p < 0.001) was significantly associated with PCa progression in multivariate analysis. The cutoff value for post-operative PSA was determined at 2 ng/mL. Among iPCa cases, 14 patients (10.4%) had both T1b stage disease and PSA ≥ 2 ng/mL, while 68 (50.7%) had neither of these factors. Univariate logistic regression analysis showed that patients with both factors had the highest risk of progression (OR 49.4; p < 0.001).

CONCLUSION

In this study, post-operative PSA above 2 ng/mL was the only independent risk factor for iPCa progression after HoLEP. Patients with post-operative PSA ≥ 2 ng/mL must be considered to be at risk of progression and may require early curative treatment or closer follow-up in the post-operative period, especially when this is associated with T1b stage disease.

The Management of Patients Diagnosed with Incidental Prostate Cancer: Narrative Review

5–14% of patients underwent surgery for benign prostate hyperplasia harboring prostate cancer (PCa) focus. The best management of incidental prostate cancer (iPCa) has been debated. The decision “treatment or no treatment” should be determined by predictors which accurately foretell PCa progression after transurethral resection of the prostate (TURP). The purpose of this study is to review the available data that can be useful in daily clinical judgment. Transrectal ultrasound prostate biopsy (TRUSBx) did not provide further Gleason score (GS) data in most patients diagnosed with iPCa. TRUSBX may be useful before active surveillance, but not in all following radical prostatectomy. The decision “treatment or no treatment” should be dependent on the expected chance of having residual cancer and clinical progression. Prostate-specific antigen (PSA) levels before and after TURP are good predictors of residual cancer after TURP. Pathological report of T0 is most likely seen in patients with low PSA density after TURP and indistinguishable lesion on multiparametric magnetic resonance imaging. The decision “treatment vs no treatment” is judged by life expectancy, tumor characteristic in the pathology report of TURP sample and PSA level following TURP. Active surveillance should be contemplated in patients with iPCa who have both prostate-specific antigen density ≤0.08 after TURP and indistinguishable cancer lesion on multiparametric magnetic resonance imaging. Patients who do not meet the criteria for active surveillance are candidates for radical prostatectomy or radiotherapy (RT). Radical prostatectomy could be peacefully done after TURP with somewhat greater morbidity. RT in patients who had a history of TURP could be safely done and is associated with acceptable quality of life.

Optimal Monitoring of Prostate-Specific Antigen Detects Prostate Cancer at the Localized Stage after Photoselective Vaporization for Benign Prostatic Hyperplasia

Introduction

Photoselective vaporization of the prostate (PVP) does not provide prostate tissue for pathologic analysis. Here, we carried out early monitoring for prostate cancer by measuring prostate-specific antigen (PSA) levels and assessing clinicopathological features after PVP.

Materials and Methods

Patients (n = 800) who underwent PVP and were followed-up for more than 12 months were analyzed retrospectively. After PVP, PSA levels were measured at 3 and 12 months and each year thereafter. Prostate biopsies were performed when PSA levels increased continuously. We assessed the characteristics of patients diagnosed with prostate cancer.

Results

The mean follow-up period was 49 months. After PVP, 54 patients underwent biopsies, and 23 patients were diagnosed with prostate cancer. Overall, 10, 10, and 3 patients had clinical stage T1c, T2a, and T2b disease, respectively, and there were no cases of stage T2c disease or greater.

Conclusions

We found that it was possible to diagnose prostate cancer at a localized stage under our optimal PSA monitoring schedule before and after PVP.

Clinical significance of multiparametric MRI and PSA density as predictors of residual tumor (pT0) following radical prostatectomy for T1a-T1b (incidental) prostate cancer

Purpose

The aim of this study was to evaluate predictors of residual tumor and clinical prognosis in T1a-T1b (incidental) prostate cancer by analysis of specimens from men undergoing surgery for benign prostatic hyperplasia.

Materials and methods

We retrospectively reviewed medical records of incidental prostate cancer patients who had undergone radical prostatectomy. Patients whose tumor statuses were further confirmed by prostate biopsy, or who had used androgen deprivation therapy before radical prostatectomy, were excluded. Clinical and pathological parameters were analyzed to evaluate residual tumor and clinical prognosis. We used univariate and multivariate logistic regression analyses, as well as receiver operator characteristics, to predict residual tumor (pT0).

Results

The final analysis included 95 patients. Among these patients, 67 (70.53%) exhibited residual tumor, whereas 28 (29.47%) did not (pT0). Pathology findings showed that 44 (65.67%), 16 (23.88%), and 7 patients (10.45%) exhibited Gleason scores of G6, G7, and ≥G8, respectively. Fifty-seven and 10 patients exhibited pathologic T stages T2 and T3, respectively. Mean follow-up duration was 70.26 (±34.67) months. Biochemical recurrence was observed in 11 patients; none were pT0 patients. Multivariate logistic regression showed that low prostate-specific antigen density after benign prostatic hyperplasia surgery and invisible lesion on multiparametric magnetic resonance imaging were significantly associated with pT0. Additionally, a combination of these factors showed an increase in the diagnostic accuracy of pT0, compared with mpMRI alone (AUC 0.805, 0.767, respectively); this combination showed sensitivity, specificity, and positive predictive values of 71.6%, 89.3%, and 94.1%, respectively.

Conclusion

Our results suggest that patients with incidental prostate cancer who have both prostate-specific antigen density ≤0.08 after benign prostatic hyperplasia surgery as well as invisible cancer lesion on multiparametric magnetic resonance imaging should be considered for active surveillance.

Temporal Trend in Incidental Prostate Cancer Detection at Surgery for Benign Prostatic Hyperplasia

OBJECTIVE

To assess changes in the rate of incidental prostate cancer (PCa) after benign prostatic hyperplasia (BPH) surgery over the last decade.

MATERIALS AND METHODS

We identified 1177 patients surgically treated for BPH (open prostatectomy, transurethral resection or holmium laser enucleation [HoLEP] of the prostate) in 2007-2016 at a single European academic center. Local polynomial regression was used to explore changes in the rate of incidental PCa detected after BPH surgery and of preoperative biopsy performed over time. Logistic regression analyses tested the association of incidental PCa diagnosis with year of surgery and preoperative biopsy.

RESULTS

Incidental PCa was found in 6.4% (74) of cases, 67 (91%) with Grade group 1 disease. We observed an increased incidence of PCa diagnosis after BPH surgery over time (odds ratio [OR]: 1.12; 95%confidence interval [CI]: 1.02-1.24, P = .02) along with a concomitant decrease in the rate of preoperative prostate biopsies (OR: 0.83; 95%CI: 0.79-0.88, P < .0001). Patients undergoing a preoperative biopsy showed a lower risk of being diagnosed with PCa after surgery (OR: 0.29; 95% CI: 0.12, 0.72 P = .007). Patients treated with HoLEP had a higher chance of incidental PCa detection (OR: 2.28; 95%CI: 1.30-4.00; P = .004), although this may be related to the significantly higher number of HoLEP performed over the last years.

CONCLUSION

The increased rate of low-risk PCa detected after BPH surgery in the last decade reflects the clinical practice changes in PCa screening and diagnosis leading to a reduced number of unnecessary biopsies and indolent cancer diagnosis.

Incidental discovery of mucinous adenocarcinoma of the prostate following transurethral resection of the prostate: A report of two cases and a literature review

Mucinous carcinoma is an unusual subtype of prostate cancer. In particular, mucinous adenocarcinomas identified following transurethral resection of the prostate (TURP) are extremely rare. The present study conducted are retrospective analysis of two cases of mucinous carcinoma of the prostate, which were incidentally diagnosed following histological examination of the specimens obtained by TURP. The pathological findings, treatment regimen and clinical course of the two cases were reviewed. One of the patients, whose surgical specimen stained positive for carcinoembryonic antigen (CEA) and negative for prostate-specific antigen (PSA), did not respond to androgen deprivation therapy (ADT). However, the other patient, whose specimen stained positive for PSA, was responsive to ADT, resulting in a better prognosis. Therefore, absence of PSA staining in surgical prostate specimens may be associated with a poor response to ADT and a worse prognosis.

Incidental prostate cancer: a 10-year review of a tertiary center, Tehran, Iran

Objective

Incidental prostate cancer (IPCa) is defined as a symptom-free cancer unexpectedly discovered upon microscopic examination of resected tissue. The aim of this study was to report the correlation between some specific clinical criteria in patients incidentally diagnosed with prostate cancer (PCa) during transurethral resection of the prostate (TURP) or open prostatectomy (OP) after clinically suspected benign prostatic hyperplasia.

Patients and methods

This was a cross-sectional, retrospective study. Data were collected from Shohada-e-Tajrish Hospital database during November 2006 to October 2016. Four hundred and twenty three men suffering from symptomatic benign prostatic hyperplasia who underwent either TURP or OP that provided a prostate specimen were evaluated. The data analysis was performed using Pearson correlation test and independent t-test using SPSS version 20 software.

Results

The mean age of subjects was 68.74±9.87 years old (45-93 years). The mean prostate specific antigen (PSA) level was 21.47±13.44 ng/mL (0.6-47.1 ng/mL). Results showed that 84 patients (19.9%) had PCa (40 patients who underwent TURP [12.6%] and 44 patients who underwent OP [40.7%] groups). Cut-off point of PSA for detecting IPCa was 3.8 ng/mL in our study, and this showed sensitivity, specificity, negative predictive value, and positive predictive value of 26.08%, 100%, 100%, and 29.79%, respectively. Twenty two patients with cancer had a positive family history for PCa; thus, a significant relationship between familial history of PCa and its occurrence was shown (p=0.0001).

Conclusion

According to the results of this study, the cut-off point for PSA levels in detecting PCa was 3.8 ng/mL, which is similar to that reported by other studies. Familial history of PCa and PSA levels were two predictors in determining the PCa.

Robotic Assisted Laparoscopic Prostatectomy Performed after Previous Suprapubic Prostatectomy

Operative management of prostate cancer in a patient who has undergone previous open suprapubic simple prostatectomy poses a unique surgical challenge. Herein, we describe a case of intermediate risk prostate cancer in a man who had undergone simple prostatectomy ten years prior to presentation. The patient was found to have Gleason 7 prostate cancer on MRI fusion biopsy of the prostate for elevated PSA and underwent an uncomplicated robot assisted laparoscopic radical prostatectomy.

Incidental prostate cancer diagnosed following a transurethral resection of the prostate: A national database analysis in England

Objectives:

The aim was to compare prostate cancer and all-cause mortality in patients diagnosed with prostate cancer following a transurethral resection of the prostate (TURP) (incidental prostate cancer, IPC), to men diagnosed with localised non-incidental prostate cancer (NIPC).

Patients and methods:

Men diagnosed with localised prostate cancer between 2000 and 2008 were identified from the English national cancer registry. Their records were linked to the Hospital Episode Statistics (HES) database of hospital admissions in England to identify men who had a TURP. Men were considered to have IPC if prostate cancer was diagnosed less than 60 days after TURP. Mortality rates were calculated using the Kaplan–Meier method. Mortality rate ratios (RR) comparing IPC and NIPC were calculated with multivariable Poisson regression adjusting for age group, co-morbidities, year of diagnosis and radical treatment.

Results:

A total of 192,960 men were included. Of these, 6666 (3.5%) had IPC and 186,294 (96.5%) NIPC. Median follow-up was 4.7 years (0.5–11.0). Ten-year prostate cancer mortality was 17.1% in IPC, 19.0% in NIPC. With adjustment, the prostate cancer-specific mortality in IPC was 30% lower than NIPC (RR 0.70, 95% CI 0.65–0.75, p<0.001), with no difference in all-cause mortality.

Conclusion:

Ten-year prostate cancer mortality in IPC was 17%. Men with IPC had lower prostate cancer-specific mortality than other prostate cancer patients.

[Comparative study of histological results between resection and biopsy of the prostate]

PURPOSE

To evaluate the histological correlation between transuretral resection chips and biopsy cores within a population of patients who underwent resection of prostate (TURP) and prostate biopsies (BPx).

PATIENTS AND METHODS

Clinical and tumoral data of 77 patients who had both procedures simultaneously or with a slight delay were collected. According to the presence of prostate cancer (Pca), 4 groups were defined: group 1 (TURP and BPx negative), group 2 (TURP positive, BPx negative), group 3 (TURP negative, BPx positive), group 4 (TURP and BPx positive). Means and proportions were compared using Anova and χ(2) test, respectively.

RESULTS

The patients were older in groups 3 and 4 (79 and 76 respectively, P=0.65). The PSA was higher in the groups 3 and 4 (64 and 55 ng/mL) than the groups 1 and 2 (10.6 et 16 respectively, P=0.23). The number of positive biopsy was higher in the group 4 than the group 3 (5.6 vs. 4.6, P<0.0001), the chips were more invaded in the group 4 than the group 2 (41% vs. 11% P<0.0001), the Gleason score at TURP was higher in the group 4 than the group 2 (7.5 vs. 6.2 P<0.0001).

CONCLUSION

Our study underlines that the Pca of transition and peripheral zones seems to have distinct characteristics. When chips of TURP and BPx were both invaded, it was due to an aggressive cancer. The decision to explore the peripheral zone in the case of positive TURP must take clinical context into consideration.

Incidental prostate cancer in transurethral resection of the prostate specimens in the modern era

Objectives. To identify rates of incidentally detected prostate cancer in patients undergoing surgical management of benign prostatic hyperplasia (BPH). Materials and Methods. A retrospective review was performed on all transurethral resections of the prostate (TURP) regardless of technique from 2006 to 2011 at a single tertiary care institution. 793 men (ages 45-90) were identified by pathology specimen. Those with a known diagnosis of prostate cancer prior to TURP were excluded (n = 22) from the analysis. Results. 760 patients had benign pathology; eleven (1.4%) patients were found to have prostate cancer. Grade of disease ranged from Gleason 3 + 3 = 6 to Gleason 3 + 4 = 7. Nine patients had cT1a disease and two had cT1b disease. Seven patients were managed by active surveillance with no further events, one patient underwent radiation, and three patients underwent radical prostatectomy. Conclusions. Our series demonstrates that 1.4% of patients were found to have prostate cancer, of these 0.5% required treatment. Given the low incidental prostate cancer detection rate, the value of pathologic review of TURP specimens may be limited depending on the patient population.

Are transrectal prostate biopsies routinely indicated in patients with incidentally diagnosed prostate cancer following transurethral resection of the prostate for benign disease?

OBJECTIVE

To determine the indication of routine transrectal ultrasound-guided needle biopsy (TRUSBx) of the prostate gland following incidental cancer diagnosis after transurethral resection of the prostate (TURP) for benign prostatic hyperplasia.

MATERIALS AND METHODS

A multi-institutional search identified 63 patients with incidental TURP-diagnosed prostate cancer from 2001 to 2010, who underwent subsequent TRUSBx or radical prostatectomy (RP). The Gleason scores from TURP were compared to those from TRUSBx or RP. Whole mount maps from RP were analysed to provide an anatomical basis for the correlation observed. To determine the clinical impact of this problem, the incidence of TURP-diagnosed prostate cancer in the population was also determined.

RESULTS

Of 22 patients who underwent TRUSBx, the rates of Gleason score concordance, upgrading and downgrading were 32, 14 and 54% respectively (Spearman correlation coefficient 0.20). Most cases of pathological downgrading consisted of benign cores at biopsy. Therefore, TRUSBx did not give additional Gleason score (GS) information in 86% of patients. Of 41 RP patients, the respective rates were 61, 22 and 17% (Spearman correlation coefficient 0.15). The majority of them retained a similar or lower GS between TURP and RP. Of 13 whole mount maps analysed, 6 (46%) were found with anterior/transitional zone (AZ/TZ) tumours, 6 (46%) with multifocal tumours and 1 (8%) with a large peripheral zone (PZ) tumour extending into the TZ. Regional population data show that despite a gradual reduction in the proportion of TURP-diagnosed cases over the past decade, they still account for 8.5-13% of all new cases.

CONCLUSION

TURP-diagnosed prostate cancers represent predominantly AZ tumours. A TRUSBx does not give additional GS information in a majority of cases, and therefore is not routinely indicated. It may be selectively useful prior to active surveillance, but not in all pursuing radical treatment. These findings may help reduce unnecessary TRUSBx in the population.

Survival after incidental prostate cancer diagnosis at transurethral resection of prostate: 10-year outcomes

BACKGROUND

The most appropriate management of incidental prostate cancers diagnosed at transurethral resection of prostate has been debated. It is important to determine the long-term outcomes to establish an appropriate management in patients with incidental prostate cancer.

AIMS

We aim to determine 10-year survival and to identify the factors of worse prognosis of incidental prostate cancers diagnosed at transurethral resection of prostate.

METHODS

A retrospective analysis of patients with pT1a-pT1b prostate cancers diagnosed between 1998 and 2003. Medical notes, PSA and pathology results were reviewed. Overall and cancer specific survival was calculated at mean 10-year follow-up.

RESULTS

Sixty patients with incidental prostate cancer were identified (pT1a = 18, pT1b = 42). Fifty-one percents of the patients were managed on a watchful waiting strategy with overall 84% survival and 9.7% cancer specific mortality. Twenty patients (all with pT1b) received hormone therapy. Overall survival in this cohort was 50% with 20% cancer specific mortality. Nine patients received curative therapy (Radical prostatectomy = 4, Radiotherapy = 5). In this group, overall survival was 88% with no cancer specific mortality.

CONCLUSIONS

Stage pT1a disease and preoperative low PSA were associated with favourable survival. However, for pT1b and/or high Gleason score (≥7), mortality was comparatively higher. Hence, patients with high Gleason score and/or pT1b disease should be considered for curative therapy. Additionally, active surveillance may have a role in selected men with incidental prostate cancer.

Risk factors for incidental prostate cancer-who should not undergo vaporization of the prostate for benign prostate hyperplasia?

BACKGROUND

Vaporization of the prostate (e.g., using laser devices) for treatment of benign prostatic hyperplasia does not allow for subsequent histological examination. Therefore, patients should be counseled about the risk of missing an incidental prostate cancer (incPCa). In this study the risk of an incPCa was determined based on all preoperative parameters.

METHODS

Thousand three hundred and fifty seven (04/2004-09/2008) patients underwent transurethral resection of the prostate (TURP) in our department. Cases with less than 10 g removed tissue, PSA >20 ng/ml or with known PCa were excluded. Data of the remaining 1,000 consecutive patients were collected retrospectively and statistically analyzed using SAS.

RESULTS

Mean age was 69.4 (36-96) years, mean PSA 4.41 (0.08-19.5) ng/ml, mean weight of removed tissue 30.9 (10-110) g. An incPCa was detected in 111 cases. Thirty-four out of these were considered to be clinically relevant (relPCa; stage T1b and/or Gleason sum ≥7). In univariate analysis age, volume of the prostate and body mass index correlated with incPCa while age, volume of the prostate and PSA correlated with relPCa. Predictive parameters for a multivariate logistic regression model are age and body mass index for incPCa and age, prostate volume, and number of prior biopsies for relPCa.

CONCLUSIONS

More than 1 in 10 patients undergoing TURP has an incPCa and 3.4% have a relPCa. Patients should be counseled carefully about the risk of missing especially relPCa when undergoing vaporization of the prostate. Our model significantly improves prediction of relPCa compared to PSA and digital examination alone.

Serum early prostate cancer antigen (EPCA) as a significant predictor of incidental prostate cancer in patients undergoing transurethral resection of the prostate for benign prostatic hyperplasia

BACKGROUND

Early prostate cancer antigen (EPCA), a nuclear matrix protein, has been recently suggested as a novel biomarker in malignant lesions of the prostate. This study was to determine whether preoperative serum EPCA levels predicted the presence of incidental prostate cancer (IPCa) in patients undergoing TURP for BPH.

METHODS

Serum EPCA levels were measured by ELISA in 449 consecutive patients with symptomatic BPH treated with TURP and 112 healthy men. Predictive performance of serum EPCA levels for IPCa were evaluated.

RESULTS

With a cutoff of 10ng/ml, serum EPCA protein had a 100% specificity for the healthy men and a 98% specificity and a 100% sensitivity in separating men with IPCa from those without. Serum EPCA levels in patients with IPCa were significantly higher than in those without and in healthy controls (17.63±2.42ng/ml vs. 5.58±1.61 ng/ml and 4.95±1.43 ng/ml, all P<0.001), whereas an indwelling transurethral catheter presence and 5α-reductase inhibitor therapy had no effect on EPCA levels (P=0.144 and P=0.238, respectively). The area under ROC curves (AUC) showed that serum EPCA level had the best predictive accuracy of all IPCa (AUC: 0.952, 95% CI: 0.912-0.981, P<0.001). Univariate and multivariate Cox regression analyses further demonstrated the independently predictive performance by preoperative serum EPCA (Hazards Ratio: 4.23, 95% CI: 3.62-6.46, P<0.001).

CONCLUSIONS

This study firstly shows that EPCA might be used as a highly sensitive and specific serum biomarker to predict IPCa presence and to help reduce the unnecessary biopsies taken before TURP in patients with BPH.

The Role of TURP in the Detection of Prostate Cancer in BPH Patients with Previously Negative Prostate Biopsy

PURPOSE

We aimed to investigate the significance of early detection of transition zone prostate cancer by transurethral resection of prostate (TURP) in benign prostatic hyperplasia (BPH) patients with lower urinary tract symptoms (LUTS) in whom prostate cancer was suspected despite a negative transrectal ultrasonography (TRUS) biopsy result.

MATERIALS AND METHODS

From January 2006 to January 2009, a total of 165 patients who underwent TURP were evaluated. The prostate cancer detection rate was compared between patients who underwent TRUS biopsy before TURP (group A) and those who did not (group B). All charts were evaluated retrospectively, including prostate-specific antigen (PSA), digital rectal examination (DRE), TURP results (including resection volume and pathology report), TRUS, and TRUS biopsy results. Group A was subdivided into group A1, who were diagnosed with prostate cancer after TURP, and group A2, who were diagnosed with BPH after TURP.

RESULTS

The cancer detection rate showed no significant difference between groups A and B (8.9% vs. 7.5%, p>0.05). The mean PSA levels in groups A1 and A2 were 15.5+/-14.0 ng/ml and 9.1+/-5.1 ng/ml, respectively (p>0.05). In group A1, 40% had an abnormal DRE, compared with 6.7% in group A2 (p<0.05). After TURP, the mean percentage of resected prostatic chips of the prostate cancer group and BPH group were 33.9% and 18.6%, respectively (p=0.001). A positive correlation was found between the detection rate of prostate cancer and PSA (p=0.01).

CONCLUSIONS

BPH patients in whom prostate cancer is suspected and who have lower urinary tract symptoms (LUTS) with a previously negative TRUS biopsy result can undergo TURP, which results in immediate improvement in bladder outlet obstruction and early diagnosis of clinically significant transition zone prostate cancer.

Long-term follow-up of conservatively managed incidental carcinoma of the prostate A multivariate analysis of prognostic factors

OBJECTIVE

To evaluate the disease-specific mortality of conservatively managed incidental carcinoma of the prostate (T1a and T1b) in relation to prognostic factors.

MATERIAL AND METHODS

Since 1987 all patients with prostate cancer have been recorded and followed in the population-based Prostate Cancer Register of the South-East Healthcare Region in Sweden, which is covered by four departments of pathology. At two of these departments, tissue was obtained from 197 consecutive, previously untreated patients (aged <80 years) with incidental carcinoma who underwent transurethral resection of the prostate between 1987 and 1991. The amount of tumour, Gleason score and levels of Ki-67, p53, chromogranin A and serotonin were determined. Univariate analysis and multiple Cox regression hazard analysis were used for analysis.

RESULTS

During follow-up (mean 7.8 years; maximum 17.5 years), 158 patients (80%) had died, 33 of them of prostate cancer, corresponding to 17% of the entire cohort. Of 86 patients with Gleason score < or =5, three died of prostate cancer. Independent predictors of disease-specific mortality in multivariate analysis were category T1b prostate cancer, Gleason score >5 and high immunoreactivity of Ki-67.

CONCLUSIONS

Elderly men with category T1a and/or Gleason score 4-5 prostate cancer have a favourable prognosis with conservative management. Immunohistochemical staining with Ki-67 may be of help in situations where further prognostic information is required.

Outcomes of radical prostatectomy for patients with clinical stage T1a and T1b disease

OBJECTIVE

To compare the outcomes between patients with stage T1a/b with those of patients with T1c cancer of the prostate treated with radical retropubic prostatectomy (RRP), as the appropriate management of clinical stage T1a/b prostate cancer is subject to debate; although many patients are managed expectantly, some have adverse pathological features suggesting that more active treatment might be beneficial.

PATIENTS AND METHODS

From 1983 to 2003, 3478 men had RRP by one surgeon. From this group, we retrospectively identified 29 men with clinical stage T1a and 83 with clinical stage T1b disease. Using statistical analysis we compared the treatment outcomes of these patients with those of 1774 men with clinical stage T1c disease.

RESULTS

Men with T1a/b disease had a significantly lower preoperative prostate-specific antigen (PSA) level, a greater proportion with organ-confined disease, and a lower mean/median prostatectomy Gleason score than those with T1c disease. Also, men with T1a/b disease were less likely to be potent before surgery, although the frequency of recovery of potency was similar among all groups. On multivariate analysis with age, year of surgery, PSA level and Gleason score, there was no statistical difference in the rates of biochemical recurrence and the 10-year overall survival rates. However, patients with T1b disease had a significantly lower cancer-specific survival.

CONCLUSIONS

T1a and T1b prostate cancer can be associated with aggressive pathological features and have a similar rate of progression as clinical stage T1c disease. That notwithstanding, most patients in the study were cured with RRP and had favourable long-term functional outcomes.

Derivatives of prostate-specific antigen as predictors of incidental prostate cancer

OBJECTIVE To search for an optimal derivative of prostate-specific antigen (PSA) identifying patients at risk of incidental prostate cancer. PATIENTS AND METHODS In all, 693 patients who underwent transurethral resection of the prostate (TURP) with a normal digital rectal examination, no history of prostate cancer and a PSA level of 2.5-10 ng/mL were studied. The total PSA (tPSA), percentage of free/total PSA (%fPSA), complexed PSA (cPSA), PSA density, cPSA density and the ratio of fPSA to cPSA were measured. Specificity, sensitivity, positive and negative predictive values were determined for all possible threshold values indicating the risk of incidental prostate cancer (T1a or T1b). Furthermore, the patients were subdivided according to age and the presence of an indwelling transurethral catheter. The areas under the receiver operating characteristic curves (AUC) were compared. RESULTS In the whole sample, the %fPSA was the best test predicting all incidental prostate cancers (AUC 0.618, reference: tPSA 0.494), whereas cPSA density was the best predictor of T1b disease (AUC 0.720, reference: tPSA 0.548). Stratification by age did not meaningfully alter the results, the presence of a transurethral catheter, however, was associated with a superiority of tests based on fPSA (AUC 0.620-0.670) compared with tests based on tPSA or cPSA (AUC 0.421-0.581). CONCLUSION Replacing tPSA by PSA derivatives (%fPSA or cPSA density) and stratifying by the presence of an indwelling transurethral catheter may improve the prediction of the risk of incidental prostate cancer and spare unnecessary biopsies before TURP in the tPSA range 2.5-10 ng/mL.

Outcome of radical prostatectomy for incidental carcinoma of the prostate

OBJECTIVE To evaluate a contemporary series of patients with incidental prostate cancer detected by transurethral resection of the prostate (TURP) and undergoing radical prostatectomy (RP). PATIENTS AND METHODS Between 1998 and 2004, 1931 patients had TURP for obstructive voiding symptoms and suspected BPH. Incidental prostate cancer was found in 104 (5.4%); 26 of these patients had a RP. The pathological staging and treatment of these patients were reviewed retrospectively and the follow-up results obtained. RESULTS Of the 26 patients who had RP, 17 had T1a and nine had T1b carcinoma of the prostate. After RP, six (35%) in the T1a group had no residual tumour (pT0) and 11 (65%) had pT2 cancer; the respective incidence in those with T1b was two and seven, with no pT3 disease in either group. The preoperative Gleason grading did not correspond well with that after RP; 30% of the patients had upgraded Gleason scores and 42% showed either downgrading or no residual tumour, with 81% having Gleason scores of <7. After a median follow-up of 47 months, one patient is receiving hormonal therapy because of biochemical relapse. Conclusion Subsequent to stringent PSA testing and prostate biopsy when indicated, the rate of incidental prostate cancer is low. Furthermore, substantially many patients will harbour either no residual cancer or tumours with favourable characteristics in their RP specimens. However, there is currently no possibility to reliably predict the absence of aggressive prostate cancer after TURP, and thus safely recommend observation instead of further therapy. Therefore, patients with incidental prostate cancer need to be counselled individually. The decision 'treatment or no treatment' should be determined by the patients' age and life-expectancy, tumour aggressiveness in the TURP specimen and the prostate-specific antigen level after TURP.

[Prostate cancer: comparative study of stage T1a and stage T1b]

OBJECTIVE

To compare the epidemiological profiles and histoprognostic factors of two groups of prostate cancer: T1a versus T1b.

MATERIALS AND METHODS

Between January 1996 and December 2005, 1359 patients were operated for benign prostatic hyperplasia (BPH) in our urology department. All patients had a PSA less than 4 ng/ml, an adenomatous prostate on digital rectal examination with a homogeneous appearance on prostatic ultrasonography. The population of patients with prostate cancer was classified into group 1 (stage T1a) and group 2 (stage T1b). The following parameters were studied: age at diagnosis, PSA, volume of prostatic tissue removed (by resection or enucleation), histological findings.

RESULTS

In this series of 1359 operated patients (762 by endoscopic resection and 597 by transvesicalprostatectomy), 44 (3.23%) had prostate cancer Group 1 comprised 18 patients (40.9%) and group 2 comprised of 26 patients (59.1%). Group 1 had a mean age of 74.7 years, a mean PSA of 2.36 ng/ml and a mean prostatic volume of 37.16 ml. Corresponding values for group 2 were 74.4 years, 3.11 ng/ml and 26.3 ml, respectively The Gleason score was low (2-4 and 5-6) and no grade 4 was observed for any of the patients of group 1, while 50% of patients of group 2 had a high Gleason score (7-10).

CONCLUSION

The incidence of stage T1a and T1b prostate cancer is low due to the increasingly systematic use of PSA. The volume of the prostate and transitional zone does not influence the stage T1a and T1b prostate cancer detection rate. T1b cancer has a poorer prognosis than stage T1a cancer.

Radical prostatectomy for incidental (stage T1a-T1b) prostate cancer: analysis of predictors for residual disease and biochemical recurrence

BACKGROUND

Controversies exist about the most appropriate management for patients with incidental prostate cancer after surgery for benign prostatic hyperplasia (BPH).

OBJECTIVES

To test the accuracy of preoperative clinical variables in predicting the presence of residual disease and biochemical recurrence in patients with incidental prostate cancer treated with radical retropubic prostatectomy.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed 126 T1a-T1b prostate cancers diagnosed at surgery for BPH between 1995 and 2007.

INTERVENTION

All patients underwent radical retropubic prostatectomy within 6 mo of surgery for BPH.

MEASUREMENTS

Univariate and multivariate logistic regression models addressed the association between the predictors (age, prostate-specific antigen [PSA] before and after surgery for BPH, T1a-T1b stage, prostate volume, and Gleason score at surgery for BPH) and the presence of residual cancer at radical retropubic prostatectomy. Cox proportional hazards regression analyses tested the relationship between the same predictors and the rate of biochemical recurrence after radical retropubic prostatectomy.

RESULTS AND LIMITATIONS

Seventy-five (59.5%) patients were stage T1a and 51 (40.5%) were stage T1b. At radical retropubic prostatectomy, 21 (16.7%) patients were pT0 and seven (5.6%) patients had extraprostatic disease (pT3). PSA before and after surgery for BPH and Gleason score at surgery for BPH were the only independent predictors of residual cancer at radical retropubic prostatectomy (all p<0.04). Stage (T1a vs T1b) did not predict residual cancer or the rate of biochemical recurrence. With a mean follow-up of 57 mo, the 5- and 10-yr biochemical recurrence-free survival rates were 92% and 87%, respectively. PSA after surgery for BPH and Gleason score at surgery for BPH were the only significant multivariate predictors of biochemical recurrence (all p<0.04). The main limitation of this study is the requirement of an external validation before implementation of the clinical recommendations.

CONCLUSION

PSA measured before and after surgery for BPH and Gleason score at surgery for BPH were the only significant predictors of the presence of residual cancer at radical retropubic prostatectomy. PSA measured after surgery for BPH and Gleason score at surgery for BPH were the only independent predictors of biochemical recurrence after radical retropubic prostatectomy.

Subclassification of clinical stage T1 prostate cancer: impact on biochemical recurrence following radical prostatectomy

PURPOSE

We investigated biochemical outcomes following radical prostatectomy across subclassifications of clinical stage T1 prostate cancer.

MATERIAL AND METHODS

Of 8,658 men who underwent radical prostatectomy for clinical stage T1 prostate cancer 85, 156 and 8,417 had clinical stage T1a, T1b and T1c disease, respectively. Age, race, prostate specific antigen, year of surgery and preoperative Gleason scores were compared across clinical stage T1 subcategories. Time to prostate specific antigen recurrence was compared among groups using Kaplan-Meier and Cox hazards modeling.

RESULTS

Patients with clinical stage T1a prostate cancer had more favorable postoperative pathological features, including lower prostatectomy Gleason scores (p <0.001), rates of extraprostatic extension (p <0.001), lymph node invasion (p <0.001) and positive surgical margins (p = 0.006). Patients with T1a cancer also showed significantly lower rates of biochemical recurrence on Kaplan-Meier analysis than men with T1b and T1c disease (log rank 0.006). Cox regression analysis adjusted for known predictors of biochemical recurrence demonstrated that clinical tumor stage in the subgroup of patients with T1 disease was not an independent predictor of biochemical recurrence (p = 0.321).

CONCLUSIONS

Men with clinical stage T1a prostate cancer who undergo radical prostatectomy have significantly lower biochemical recurrence rates than men with stage T1b or T1c disease. However, subclassification of tumors in this group of patients was not an independent prognostic factor for biochemical recurrence after accounting for preoperative variables, including prostate specific antigen and Gleason score.

The rising prevalence of androgen deprivation among older American men since the advent of prostate-specific antigen testing: a population-based cohort study

OBJECTIVE

To investigate the effect of efforts in the early detection of prostate cancer using prostate-specific antigen (PSA) testing in the USA, by estimating the regional prevalence of androgen deprivation therapy (ADT) among older men in 1993-2000, and correlating the prevalence with early detection and aggressive treatment rates in 1987-91, as some authors predicted that ADT, a treatment traditionally reserved for advanced prostate cancer, would become less common over time as a result of such efforts.

PATIENTS AND METHODS

A sample of 5% of men who were Medicare beneficiaries was used in this prospective population-based cohort study. The main outcome measures were the overall prevalence of ADT (medical and surgical) in the cohort from 1993 to 2000, and correlations between rates of prostate procedures in the 306 USA hospital referral regions in 1987-91 and prevalence of ADT in those regions from 1993 to 2000.

RESULTS

The prevalence of ADT among these men in the USA increased steadily from 1.8% in 1993 to 2.9% in 2000 (P < 0.001). Regions with higher rates of prostate biopsy in 1987-91 had a higher prevalence of ADT in 1993, 1995 and 1997 (P < 0.05). Regions with higher rates of transurethral prostatectomy in 1987-91 had a higher prevalence of ADT in 1993-2000 (P < 0.01). Regions with higher rates of radical prostatectomy in 1987-91 had higher rates of ADT in 1993-99 (P < 0.05).

CONCLUSIONS

Widespread early detection and aggressive treatment for prostate cancer in the USA has been associated with more, not less, ADT among older men over time.

Cáncer de próstata incidental: T1a-T1b. Nuestra experiencia tras observación/intervención radical y revisión de la literatura

OBJECTIVES

To analyse the progress of T1a and T1b prostate cancer diagnosed in our hospital.

MATERIAL AND METHODS

Retrospective study of 40 patients in T1a-T1b clinical stage diagnosed with prostate adenocarcinoma in our hospital, from 1986 to 1999. A restaging biopsy was performed on the 16 T1a patients after initial diagnosis and control. A radical prostatectomy was performed on the 24 T1b patients. They were all monitored every six months with rectal exam and PSA. We analysed biological and/or clinical progression, time to progression, mortality caused by the tumour and survival.

RESULTS

None of the 16 patients with T1a clinical stage presented tumour progression, with a median follow-up of 90 months. 12,5% of the 24 T1b cases presented tumour progression, with a median follow-up of 70 months. Cancer-specific mortality was one patient (4,16 %) in the T1b group.

CONCLUSIONS

Observation and follow-up with PSA and rectal exam appears to be a good option for T1a clinical stage, given the good prognosis. Our results show that patients with T1a clinical stage and good prognostic factors could be at a similar risk of suffering from a new prostate cancer as the normal population, although prospective studies are required to validate these results. T1b cases require active treatment and closer monitoring.

A hybrid technique using bipolar energy in transurethral prostate surgery: a prospective, randomized comparison

PURPOSE

We assessed the efficacy and safety of transurethral resection and vaporization with bipolar PlasmaKinetic energy.

MATERIALS AND METHODS

During a 2-year period 101 men with benign prostatic hyperplasia were randomly assigned to PlasmaKinetic surgery or standard transurethral prostate resection (TURP). Patient demographics, indications for surgery, preoperative and postoperative International Prostate Symptom Score, uroflowmetry scores, operative time, catheterization duration, hospital stay and complication rates were compared.

RESULTS

Complete data on 96 patients with a mean age +/- SD of 69.1 +/- 6.1 years was available at a mean followup of 18.3 +/- 6.7 months (range 12 to 23). In the PlasmaKinetic and TURP groups mean operative time was 40.3 +/- 11.4 (range 30 to 60) and 57.8 +/- 13.4 minutes (range 45 to 75), respectively (p <0.01). The mean volume of saline irrigation during the PlasmaKinetic procedure was significantly lower than that of hyperosmolar solution irrigation during TURP (p <0.05). Patients in the PlasmaKinetic and TURP groups were catheterized a mean of 2.3 +/- 0.7 (range 2 to 4) and 3.8 +/- 0.7 days (range 3 to 5), respectively (p <0.05). The mean improvement rate from baseline at month 12 in International Prostate Symptom Score and the maximal urinary flow rate was similar in the 2 groups. Severe irritative symptoms were the most common complaints after PlasmaKinetic surgery, as observed in 6 cases (12.2%). Recatheterization was necessary in 3 cases (6.1%) cases in the PlasmaKinetic group and in 1 (2.1%) in the TURP group. During followup urethral stricture formation was observed in 3 patients (6.1%) cases in the former group and in 1 (2.1%) in the latter group (p = 0.002). Reoperation was required in 2 (4.1%) and 1 (2.1%) cases in the PlasmaKinetic and TURP groups, respectively.

CONCLUSIONS

: Transurethral surgery with PlasmaKinetic bipolar energy seems to be a promising alternative to prostatic tissue removal with shorter operative, catheterization and hospitalization times, although increased rates of postoperative irritative symptoms and urethral stricture formation must be further evaluated.

[Prostate cancer: Diagnosis and staging]

The discovery and the use of serum prostate specific antigen (PSA) has considerably improved the diagnosis of prostate cancer during the past 20 years. Before PSA era, early diagnosis was only based on the digital rectal examination (DRE) of which the Limitations have been evidenced; over half of the tumours diagnosed by such means had already spread out of the prostate and were incurable. Assessment of serum PSA has allowed the diagnosis to be made at an earlier stage of the disease, curable by current treatments. Whichever the diagnostic tools, transrectal ultrasound (TRUS) prostatic biopsies remain necessary for diagnosis ascertainment, taking into account the low specificity of PSA assessment. The feasibility of a diagnosis at an early and curable stage of the disease has logically resulted in screening procedures aimed at reducing the high mortality related to prostate cancer. The numerous publications on prostate cancer screening provide precise information on the accuracy of available diagnostic means (PSA, DRE, TRUS, combined PSA and DRE), on the characteristics of screened tumours (stage and differentiation), and also on the population of men likely to benefit from the screening (age at beginning and end of the screening, frequency of PSA testing, identification of the men with ethnic and/or genetic predisposition). In those early diagnosed prostate cancers, the assessment of loco-regional cancer extension (extracapsular and/or, microscopic nodal involvement), remains unsatisfactory because no imaging technique (ultrasonography, CT scan, MRI,...) allows visualising the tumour itself or microscopic metastases. Nevertheless, the combination of multiple parameters such as DRE data, PSA level, biopsy data and tumour differentiation helps approaching with an increasing precision (nomograms) the true pathologic stage of the disease. Such advances allow distinguishing, among the very heterogeneous group of prostate cancers, tumours that differ from one to another in terms of disease stage, progression and prognosis, which is helpful for the determination of an adapted therapeutic strategy.

[Prostate cancer. Treatment]

The discovery and the utilisation of the prostate specific antigen (PSA) that allows early diagnosis of prostate cancer, have considerably improved the management of this disease. Before the PSA era, prostate cancer was just a disease of the old man, generally detected at an advanced stage and incurable, with a fatal outcome delayed by the androgenic deprivation. Since early 1990's, prostate cancer has become primarily a disease of the man of 60 years, detectable earlier, and curable provided no extraprostatic dissemination has occurred. Early treatment of prostate cancer has benefited from important advances in surgical and radio-therapeutic techniques (conformational irradiation, brachytherapy), with, as principal goal, the combination of a better survival and the reduction of the potential adverse effects that alter quality of life. A better definition of the characteristics of the tumours in terms of progression regarding various parameters (clinical stage, PSA, tumoral differentiation) have resulted, despite the heterogeneity of the disease, in the determination of subgroups of tumours with different prognosis, which leads to an improved therapeutic strategy. The assessment of men's life expectancy (< or > 10 years) is the second primary parameter on which is based the indication for curative or non curative therapy in case of localized tumour. Roughly, before the age of 75, a curative therapy is indicated whereas after this age a surveillance is reasonable as first-line treatment, followed by hormone therapy in case of onset of symptoms indicating some progression of the disease (urinary symptoms, bone lesion). At a Later stage, in case of a metastatic or locally advanced cancer, hormone therapy by androgenic deprivation is highly indicated. The hormone sensitivity characterizes prostate cancer; it has been discovered more than 50 years ago by Charles Huggins (Nobel prize-winner). This hormone therapy is a palliative treatment since its efficacy is transient (ineluctable occurrence of hormone resistance in a variable time delay), but it constitutes an essential therapeutic means with a well-established efficacy. Hormone therapy has progressively improved, with the renunciation of oestrogen therapy and surgical castration which has been replaced by luteinizing hormone-releasing hormone (LH-RH) analogues, and/ or anti-androgens. Numerous works have resulted in a better rationalization of the prescription (date of treatment initiation, interest of combined androgenic deprivation, ...) but uncertainties remain, such as the therapeutic interest of intermittent treatment, or of earlier hormone therapy combined with the treatment of the primitive tumour (adjuvant hormone therapy). Finally, at the time of the hormonal escape of which the molecular mechanisms remain unclear, no therapy has proven any efficacy in survival lengthening, and the treatment remains palliative and symptomatic. Although improved knowledge of prostate cancer aetiology is expected for a real disease prevention, early diagnosis at a curable stage of the disease (by PSA assessment) remains the only means for mortality reduction.

Distribution of inflammation, pre-malignant lesions, incidental carcinoma in histologically confirmed benign prostatic hyperplasia: a retrospective analysis

OBJECTIVES

We analyze our experience on BPH through 20 years of histopathological examinations performed by the same pathologist.

METHODS

We retrospectively reviewed all histopathological examinations performed from January 1979 to December 1998 in patients undergoing surgery in our urological clinic who were diagnosed with BPH. We limited our evaluation to the following variables in each BPH case analyzed: inflammatory aspects associated with BPH, presence of focal acinar atrophy, atypical adenomatous hyperplasia (AAH), prostatic intraepithelial neoplasia (PIN), incidental prostate carcinoma (IC). These histological variables were analyzed according to some clinical parameters such as age, prostate volume and serum PSA.

RESULTS

The study population was comprised of 3942 cases with histological diagnosis of BPH. The mean patient age was 68.85+/-7.67 years. In particular, inflammatory aspects were associated with BPH in a high percentage of cases (43.1% =1700 cases), predominantly as chronic inflammation. Observation of focal acinar atrophy significantly increased according to patient decade of age (p=0.027). There was a significant trend to increase with age decades (p=0.036) for high grade PIN. A significant difference was found in IC (T1a, T1b) distribution in the different decades of age and especially in regards to both T1a and T1b tumors, there was a trend to increase with patient age (p=0.020 and p=0.025, respectively). On the contrary, the distribution of inflammatory aspects (p<0.001) and AAH (p=0.003) significantly varied according to prostate volume, and particularly in regards to chronic inflammation, there was a trend to increase depending on the prostate volume (p=0.002). Only the presence of T1b tumor but not of the other histological parameters associated to BPH, was able to significantly influence serum PSA.

CONCLUSION

In our analysis different histological variables associated to BPH are differently influenced by the age of patients and prostate volume, and they differently influence serum PSA levels.

Free/total PSA ratio does not improve prediction of pathologic stage and biochemical recurrence after radical prostatectomy

OBJECTIVES

Despite several publications, the ability of the free/total (F/T) prostate-specific antigen (PSA) ratio to predict the pathologic extension of prostate cancer is still a matter of controversy. In addition, its ability to predict biochemical recurrence after radical prostatectomy has not yet been reported.

METHODS

Since January 6, 1996, the F/T PSA ratio was prospectively measured preoperatively in 343 patients undergoing radical prostatectomy as the first treatment for localized prostate cancer.

RESULTS

The ability to predict organ-confined disease was measured by receiver operating characteristic analysis. The areas under the curve were 0.66 for PSA density, 0.61 for total PSA, 0.60 for Gleason score, and 0.587 for the F/T PSA ratio. In multiple logistic regression analyses, the F/T PSA ratio was not a relevant predictor of organ-confined disease (Wald statistic 0.345 for P = 0.55). Similar results were obtained in the subgroup of patients with a PSA level between 2.5 and 10 ng/mL. The biochemical survival for the 270 patients who did not receive adjuvant therapy was 86% at 61 months. Statistically significant univariate predictors (P <0.05) of PSA recurrence were pT stage (log-rank 18.2) and Gleason grade (log-rank 8.8). The F/T PSA ratio was not a significant predictor of recurrence in the univariate analysis (log-rank 3.6 for P = 0.314) and in multivariate analysis (Wald statistic 0.2 for P = 0.97).

CONCLUSIONS

These results suggest that the F/T PSA ratio is not helpful for the prediction of organ-confined disease and PSA recurrence after radical prostatectomy.

Undiagnosed macroscopic haematuria revisited: a follow-up of 146 patients

OBJECTIVE

To further investigate a group of patients with macroscopic haematuria who had no abnormalities on upper tract imaging and cystoscopy, to determine the appropriate follow up.

PATIENTS AND METHODS

The hospital notes of patients who presented with frank haematuria between 1990 and 1998 and had no abnormality on cystoscopy and/or upper tract imaging were reviewed, with particular note made of any further bleeding or any other further urological problems. Those with < 2 years of follow-up in the hospital notes were investigated by telephone or via their general practitioner to ensure that all patients had at least 2 years of follow-up after the initial investigation.

RESULTS

Of the 146 patients in the study, 98 were alive and had no more bleeding after the initial investigation. None of them were found to have renal or urothelial tumours during the follow-up. Thirty-three patients had recurrent episodes of bleeding after the initial investigation; 26 of these had repeat investigations and one was found to have a renal pelvic transitional cell carcinoma on repeat intravenous urography. One patient in this subgroup had died from a subarachnoid haemorrhage; 15 other patients had died, 13 of non-urological causes and two of unknown causes.

CONCLUSIONS

Of 146 patients with undiagnosed macroscopic haematuria, only one had a missed tumour and this was detected on further investigation for recurrent bleeding. These results confirm that repeat cystoscopy and upper tract imaging is only warranted in patients who have recurrent bleeding after initial investigation.