Transdermal estradiol improves bone density when used as single agent therapy for prostate cancer

PURPOSE

Current androgen deprivation therapies for men with prostate cancer cause accelerated osteoporosis and a significant risk of osteoporotic fracture. We have recently shown that transdermal estradiol is an effective alternative for such patients. Here we report the impact of transdermal estradiol therapy on the bone mineral density of men with prostate cancer.

MATERIALS AND METHODS

A total of 20 patients with newly diagnosed locally advanced or metastatic prostate cancer were treated with transdermal estradiol patches. Bone mineral density of the lumbar spine and the proximal femur was measured with dual-energy x-ray absorptiometry, and correlated with computerized tomography and isotope bone scan findings at 6-month intervals.

RESULTS

In all measured regions bone mineral density increased with time. By 1 year mean bone mineral density +/- SEM had increased by 3.60% +/- 1.6% in the lumbar spine (p = 0.055), 2.19% +/- 1.03% in the femoral neck (p = 0.055), 3.76% +/- 1.35% in the Ward's region (p = 0.008) and 1.90% +/- 0.85% in the total hip (p = 0.031), respectively. Of 12 osteoporotic sites 4 had improvement based on World Health Organization grading. All other sites improved toward a better classification.

CONCLUSIONS

Transdermal estradiol protects against bone loss in men with prostate cancer and may improve bone density in those at risk for osteoporotic fracture.

Pressure flow study data in a group of asymptomatic male control patients 45 years old or older

PURPOSE

The role of pressure flow studies in the routine evaluation of patients with benign prostatic hyperplasia remains a controversial issue in urological practice. There are little data on age matched asymptomatic control groups. We evaluated pressure flow findings in such a group.

MATERIALS AND METHODS

A total of 24 male patients 47 to 80 years old (mean age 62.5) attending a general surgical clinic were recruited for study after ethical committee approval. The volunteers had never sought medical attention for urinary symptoms and did not perceive themselves as having a urological problem. Volunteers were assessed by International Prostate Symptom Score (I-PSS) and Madsen symptom score, clinical examination, free uroflowmetry, post-void residual ultrasound, repeat pressure flow studies and transrectal ultrasonography. Pressure flow tracings were manually analyzed for standard urodynamic values and the degree of bladder outflow obstruction according to recognized International Continence Society, Abrams-Griffith nomogram, linear passive urethral resistance relation and urethral resistance factor classifications.

RESULTS

Median I-PSS was 2.0 (interquartile range 1.2 to 5.7). For I-PSS quality of life the median was 1.0 (interquartile range 0.75 to 2.0). On pressure flow studies 3 patients (13%) had unequivocal obstruction, 7 (29%) were in the equivocal area and 14 (58%) had no obstruction, while 15 (63%) had unstable contractions on medium fill cystometry.

CONCLUSIONS

The data show that a surprising number of apparently normal men are obstructed by commonly used criteria. This finding confirms asymptomatic obstruction, suggesting that obstruction may be less important in the development of symptoms than previously thought. Also, until the natural history of obstruction is more clearly defined surgery in obstructed asymptomatic patients is probably unwise.

Analysis of outcome after thermotherapy using different classifications of bladder outlet obstruction

The urodynamic profiles of 97 patients with benign prostatic hyperplasia undergoing low-energy transurethral microwave thermotherapy (TUMT) for lower urinary tract symptoms were analysed using the Abrams/Griffiths nomogram, the urethral resistance algorithm, the linPURR, Schäfer nomogram, and the CHESS classification. A significant clinical response was seen for the whole group, as shown by changes in symptom score, free flow rate, and residual urine. The best symptomatic response was identified in patients in whom obstruction was present, whatever the classification used. Only the two-dimensional CHESS classification was found to predict a group of patients with a better response in both symptoms and objective variables. Obviously, a better response from TUMT can only be predicted by a classification system that identifies the independent variables of footpoint and slope of the PURR. The CHESS classification was the only one of those studied that satisfactorily identified these two parameters and could be used as a system of case selection for this minimally invasive treatment.

The diagnosis of bladder outlet obstruction in men by ultrasound measurement of bladder wall thickness

PURPOSE

The objective of the study was to investigate specificity and sensitivity of bladder wall thickness in the diagnosis of bladder outlet obstruction.

MATERIALS AND METHODS

The study included 174 patients referred to our prostate centers for lower urinary tract symptoms. Free uroflowmetry and pressure-flow studies were performed in duplicate as part of the diagnostic evaluation. After the 2 voiding studies were done the bladder was filled to 150 ml. and wall thickness was measured via suprapubic ultrasound. Bladder outlet obstruction was diagnosed and graded according to the Abrams-Griffiths and Schäfer nomogram as well as to the group specific urethral resistance algorithm.

RESULTS

A significant correlation (r > 0.6, p < or = 0.007) was found between bladder wall thickness and all parameters of the pressure-flow study. A bladder wall thickness of 5 mm. appeared to be the best cutoff point to diagnose bladder outlet obstruction, since 63.3% of patients with bladder wall thickness less than 5 mm. were unobstructed while 87.5% of those with a bladder wall thickness 5 mm. or greater were obstructed. Bladder wall thickness out performed uroflowmetry in terms of specificity and sensitivity in the diagnosis of outlet obstruction as demonstrated by an area under curve value of 0.860 versus 0.688 in the receiver operator characteristics analysis.

CONCLUSIONS

Measurement of bladder wall thickness appears to be a useful predictor of outlet obstruction with a diagnostic value exceeding free uroflowmetry although it does not represent a substitution to invasive urodynamics. These data support the hypothesis that the relationships between morphology and function are of clinical importance.

Histopathological study of 110 cystectomy specimens for bladder cancer by an original mapping method

The management of cystectomy specimens represents the first and most important step in the study of bladder cancer and related lesions. We carried out a study on 110 patients, applying an original mapping protocol which allowed to determine the exact topography of lesions, recognizing even the smallest ones and putting in evidence some rare histotype. A prevalence of high-grade, high-stage tumors was noted, as well as a remarkable frequency of precancerous lesions, mostly found in Brunn's nests. This latter finding could mean that in many cases a flat carcinoma becomes invasive within a Brunn's nest rather than in surface urothelium. We were also able to accurately evaluate prostatic pathology, finding incidental malignant lesions of this gland in 24.2% of the cystectomized males. The apparently worst prognosis of the patients who underwent chemotherapy depends on the fact that they had grades and stages higher than the untreated subjects. In conclusion, we believe that a more extensive sampling of cystectomy specimens gives highly reliable prognostic data and represents an unreplaceable tool in understanding bladder neoplasms.

Manual versus computer methods for diagnosing obstruction from pressure-flow tracings in patients with benign prostatic hyperplasia

PURPOSE

We compared manual versus computer analysis of pressure-flow tracings for diagnosing bladder outlet obstruction in patients with benign prostatic hyperplasia.

MATERIALS AND METHODS

A total of 105 patients with a clinical diagnosis of prostate enlargement and lower urinary tract symptoms was included in the study irrespective of free flow rates. Pressure-flow studies were performed in duplicate and tracings were evaluated by 2 independent investigators blinded to patients status. Manual reading of urodynamic printouts and fully computerized analysis using CLIM software were done. All urodynamic parameters relevant to the diagnosis of outlet obstruction were compared using the Abrams-Griffiths and Schäfer nomograms. Group specific urethral resistance factors were also compared.

RESULTS

There was good correlation between manual and computer derived values of maximum flow (r = 0.9874, p < or = 0.0001), detrusor pressure at maximum flow (r = 0.9943, p < or = 0.0001), minimum detrusor pressure during voiding (r = 0.8816, p < or = 0.0001) and group specific urethral resistance factor (r = 0.9917, p < or = 0.0001). The diagnosis of outlet obstruction according to the group specific urethral resistance factor, and the Abrams-Griffiths and Schäfer nomograms was highly consistent using the manual and computerized approaches.

CONCLUSIONS

Manual analysis of pressure-flow tracings generated by urodynamic equipment and digital data obtained by CLIM software appeared to be highly consistent and equally reliable for diagnosing and grading outlet obstruction.

Vitamin D3 reduces the apoptotic effect of IFN-gamma but does not facilitate HLA class II inducibility in RB-defective cells

The retinoblastoma protein (RB) regulates the cell cycle by binding and inactivating the E2F transcription factors, which prevents transcription of genes required for DNA synthesis. RB has been shown to inhibit IFN-gamma-mediated apoptosis, possibly by regulating premature entry into S phase. RB is also required for high level IFN-gamma induction of HLA class II genes, which encode antigen presenting molecules, but not for other IFN-gamma inducible genes as demonstrated in previous reports describing the analysis of RB-transformants of the RB-defective cell lines, MDA-468-S4 (S4) and H2009. The IFN-gamma response of the HLA class II genes takes much longer than does the response of the other IFN-gamma inducible genes, raising the question of whether RB facilitates HLA class II inducibility by maintaining cell viability over the long time course required for HLA class II induction. Thus, we sought to learn whether IFN-gamma induced apoptosis in an RB-defective cell line could be prevented independently of RB and whether doing so would facilitate HLA class II inducibility in the RB-defective line. Our results indicated that cotreating the RB-defective S4 cells with IFN-gamma and Vitamin D3 decreased the number of cells containing subdiploid DNA compared to cells treated with IFN-gamma alone, suggesting that Vitamin D3 reduced IFN-gamma-mediated apoptosis. S4 cells cotreated with Vitamin D3 and IFN-gamma also had decreased cell detachment, further indicating that Vitamin D3 decreased IFN-gamma induced apoptosis. However, Vitamin D3 cotreatment resulted in no detectable increase in HLA-DR, the most prominent HLA class II molecule, indicating that the effect of RB on HLA class II induction is not exclusively due to its ability to inhibit IFN-gamma induced apoptosis.

Three-year followup of patients treated with lower energy microwave thermotherapy

PURPOSE

A retrospective study was done to investigate the long-term outcome of patients treated with lower energy transurethral microwave thermotherapy.

MATERIALS AND METHODS

A total of 305 patients with lower urinary tract symptoms and benign prostatic hypertrophy underwent transurethral microwave thermotherapy according to a similar protocol at 2 centers.

RESULTS

After 3 years of followup 133 patients who had undergone transurethral microwave thermotherapy alone were available for study. During this observation period significant symptomatic improvement from baseline and an improved maximum flow rate of 2.6 ml. per second were noted. Of the patients 125 underwent invasive or medical treatment.

CONCLUSIONS

After 3 years of followup lower energy transurethral microwave thermotherapy showed significant and durable improvements in baseline parameters in 52% of the patients.

Pressure-flow study analyses in patients treated with high energy thermotherapy

PURPOSE

We evaluated the urodynamic changes after high energy microwave thermotherapy in patients with lower urinary tract symptoms and benign prostatic enlargement.

MATERIALS AND METHODS

A total of 120 patients was available for analysis with urodynamic investigation and pressure-flow studies before and 6 months after treatment. Several obstruction parameters were used to evaluate treatment outcome.

RESULTS

A significant decrease (p < 0.001) in all obstruction parameters was noted. Mean detrusor pressure at maximum flow decreased from 64.7 to 39.1 cm. water, urethral resistance factor from 41.8 to 23.5 cm. water and linear passive urethral resistance relation from 3.0 to 1.4. Analysis of subgroups showed better results in patients with greater degrees of obstruction.

CONCLUSIONS

High energy thermotherapy results in a significant and substantial decrease in bladder outlet obstruction.

High energy thermotherapy in the treatment of benign prostatic hyperplasia: results of the European Benign Prostatic Hyperplasia Study Group

PURPOSE

We documented the results of high energy transurethral microwave thermotherapy in the treatment of benign prostatic hyperplasia.

MATERIALS AND METHODS

We evaluated 116 patients following transurethral microwave thermotherapy according to symptom scores, transrectal ultrasound, free voiding and pressure-flow study parameters.

RESULTS

Significant improvement was noted in all objective and subjective parameters. Moreover, cavities in the prostatic urethra were observed in almost 40% of the patients.

CONCLUSIONS

High energy transurethral microwave thermotherapy is an effective therapy for benign prostatic hyperplasia. Patients with larger prostates and moderate to severe bladder outlet obstruction seem to be the best candidates for this higher energy thermotherapy protocol, although morbidity is increased.

A 12-month study of the placebo effect in transurethral microwave thermotherapy

OBJECTIVE

To determine the placebo effect of transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic enlargement (BPE).

PATIENTS AND METHODS

A prospective, randomized sham-controlled study in 93 patients (mean age 65, range 50-88) was conducted at two centres comparing TUMT or a sham treatment. Patients randomized to receive sham treatment underwent the same initial procedure as for TUMT, but the complete procedure was simulated on the visual display with no application of microwave energy. If the patient's condition had not improved after 3 months, a second genuine TUMT treatment was given at the patient's request.

RESULTS

After 3 months there were significant clinical and statistical differences in efficacy between the groups; 62% and 18% of patients had a > 50% improvement in symptom score in the treated and sham groups, respectively (P = 0.001). The corresponding changes in flow rate were 36% and 11% (P = 0.002), respectively. After 1 year, 63 patients were divided into those that had TUMT initially, those that had sham initially but subsequently had TUMT and those whose sham procedure had led to sufficient clinical improvement to require no further treatment. The two treated groups had a significant improvement over the sham group.

CONCLUSION

The benefit from TUMT cannot be due to a placebo effect alone.

Responders and nonresponders to transurethral microwave thermotherapy: a multicenter retrospective analysis

PURPOSE

We attempted to identify any parameter that could possibly lead to a successful treatment outcome after transurethral microwave thermotherapy.

MATERIALS AND METHODS

Clinical parameters and treatment profiles of 292 patients were analyzed in a retrospective multicenter manner. Responder and nonresponder groups were identified according to a given definition.

RESULTS

No statistically significant differences in baseline characteristics were found. Responders showed a 76% symptomatic improvement rate compared to 27% in nonresponders, and an 82% improvement rate in peak flow compared to a 5% decrease in nonresponders. Responders also showed a significantly greater increase in posttreatment PSA level and a significantly greater amount of energy released during treatment.

CONCLUSIONS

No baseline clinical parameter is capable of predicting treatment outcome.

Changes in pressure-flow parameters in patients treated with transurethral microwave thermotherapy

PURPOSE

We document changes in pressure-flow study parameters in patients treated by transurethral microwave thermotherapy.

MATERIALS AND METHODS

Pressure-flow study tracings before and after therapy from 75 patients with benign prostatic hyperplasia were analyzed. Patients were stratified according to the predominant type of obstruction at screening (constrictive or obstructive).

RESULTS

An improvement in Madsen score and flow rates was noted at 6 months in both groups. In contrast to compressive obstruction patients, however, those with constrictive obstruction also showed significant changes in pressure-flow study parameters, including detrusor pressure at maximum flow, maximum flow rate and urethral resistance factor.

CONCLUSIONS

Patients with predominantly constrictive obstruction are the best candidates for microwave thermotherapy.

The prediction of clinical outcome from transurethral microwave thermotherapy by pressure-flow analysis: a European multicenter study

A total of 100 patients treated with a single session of microwave thermotherapy at 4 European centers was stratified according to 2 different types of obstruction (constrictive and compressive) and compared to clinical outcome at 6 months. Patients had a Madsen-Iversen score of 8 or more, maximum flow rate of 15 ml. per second or less and residual urine volume of 300 ml. or less at entry. The change in Madsen-Iversen score was the same in the 2 groups. Maximum flow rate increased from 8.71 +/- 2.62 to 14.73 +/- 4.04 ml. per second in the constrictive group, and from 8.54 +/- 2.26 to 10.41 +/- 4.52 in the compressive group (p < or = 0.0001). Residual urine decreased from 96.00 +/- 72.85 to 40.34 +/- 56.33 ml. in the constrictive group and from 109.86 +/- 67.09 to 84.65 +/- 81.45 ml. in the compressive group (p < or = 0.0001). Success, as defined by an increase of 50% or more in maximum flow rate and Madsen-Iversen score, was noted in 68% of the constrictive but only 15% of the compressive groups (p < or = 0.0001 chi-square test for trend). Selection by pressure-flow criteria for patients being considered for thermotherapy should improve the overall clinical results.

Ultrasonic detection of non-palpable seminal vesicle invasion: a clinicopathological study

In an effort to identify reliable criteria for detecting seminal vesicle invasion (SVI) with transrectal ultrasonography (TRUS) in patients with clinically localised prostate cancer, we reviewed the pre-operative sonograms in 230 patients who underwent radical retropubic prostatectomy; 49 patients (21%) had pathologically confirmed SVI. Conventional sonographic criteria for SVI (asymmetry, distension, atrophy, abnormal echogenicity and irregularity in outline) were present in 58 patients, but only 16 (28%) had pathologically confirmed SVI. On the basis of the results of a preliminary comparison of radical prostatectomy specimens and TRUS, we had revised our criteria for the recognition of SVI: (1) a hypoechoic lesion at the base of the prostate (within 10 mm of the seminal vesicle); (2) an "adhesion sign" resulting from the loss of the echo reflections from the normal fat plane between the prostate and the seminal vesicle; (3) "posterior convexity" of the seminal vesicles. When we reviewed the 230 sonograms retrospectively, we found a hypoechoic tumour at the base in 70 patients, of whom 37 had SVI (positive predictive value (PPV) 53%). An adhesion sign was found in 16 patients, 12 of whom had SVI (PPV 75%). Posterior convexity was present in 4 patients, all of whom had SVI. If any one of our sonographic signs was present, the overall accuracy (83%), sensitivity (90%) and positive predictive value (51%) were significantly better than with any one of the conventional criteria. Patients with SVI were also more likely to have a high serum prostate specific antigen (PSA) level. The PPV for SVI of a PSA level > or = 10 ng/ml was 38%. If the PSA was > 10 ng/ml and TRUS was positive (> or = 1 of our sonographic criteria), 16 (62%) of 26 patients had SVI. If the PSA was < 10 ng/ml and TRUS was negative, only 3 (3%) of 86 patients had SVI. It was concluded that the conventional criteria for detecting SVI on ultrasonography are not accurate in patients with early stage prostate cancer. There are, however, reliable criteria that predict SVI with reasonable accuracy and these criteria, combined with the serum PSA levels, can stratify patients into those with a low risk and those with a high risk of SVI.

Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction

Transurethral microwave thermotherapy (TUMT) is a single-session, minimally invasive outpatient treatment for patients with symptoms of benign prostatic bladder outflow obstruction. We designed a prospective randomised trial to identify any placebo response. Patients with a Madsen symptom score over 8 for at least 6 months were eligible for study. Two measurements of urinary flow less than 15 mL/s and a residual urine of under 350 mL were also required for entry. Patients with renal dysfunction, upper urinary tract disease, co-existing bladder disease, and malignant prostatic change were excluded. 43 patients were studied: 21 were randomised to receive a sham treatment and 22 to thermotherapy. Sham treatments were done with the urethral applicator in situ. 40 patients were available for evaluation at 3 months. 2 patients had delayed follow-up and 1 patient randomised to TUMT has undergone transurethral resection. The thermotherapy group showed a 70% decrease (from 14.5 to 4.3) in the mean Madsen score, a 53% increase in flow-rate (8.5 to 13.0 mL/s), and 92% decrease in residual urine volume (147 to 12 mL). No significant change was seen in these mean indices in the sham group. There was no difference in the main complication of transient haematuria between the two groups. However, there was a 22% frequency of acute retention in the TUMT group. The results show little significant placebo component to the subjective and objective improvement that occurs in patients who have received TUMT.

Sonographic monitoring of prostate cancer after definitive radiotherapy

Thirty patients who had transrectal ultrasonography before and after definitive radiotherapy were studied retrospectively to determine the effects of radiotherapy on the sonographic appearance of prostate cancer. Before therapy one or more discrete hypoechoic areas characteristic of cancer were present in 29 (97%) of the patients. In 10 patients (34%) the hypoechoic areas disappeared six to twenty-seven months (mean 11.4) after radiotherapy, but in 3 of these the hypoechoic lesion subsequently reappeared. Six months after radiotherapy a hypoechoic lesion could still be seen in the original area in 79 percent of 19 patients studied. Sonography showed persistent lesions in 65 percent of 17 patients at twelve months, in 79 percent of 14 patients at twenty-four months, and in 75 percent of 8 patients at thirty-six months. In 9 of the 29 patients (31%), there was a measurable increase in the size of the lesion, but overall, the size (maximum diameter) of the hypoechoic lesion had decreased by a mean of 41 percent when evaluated twelve months after radiotherapy. Previous studies from our laboratory have shown that persistent prostate cancer after definitive radiotherapy retains its hypoechoic appearance, and this study indicates that these characteristic hypoechoic lesions can be monitored by transrectal ultrasound.

Abdominal wall tenderness: a useful sign in chronic abdominal pain

The outcome in 72 patients with obscure abdominal pain and a positive Carnett's (abdominal wall tenderness) test, seen in one firm's surgical outpatient clinic between 1975 and 1983, was sought by a combination of hospital note retrieval and general practitioner questionnaire. Full follow-up data to date or death were available for 58 (81 per cent) patients and partial follow-up for 14 patients. The study showed that the patients generated a good deal of investigation and a number of surgical procedures but that seldom were their symptoms attributable to serious pathology. Familiarity with the test, taken in the context of a proper history and examination, has been found helpful in assessing such patients and saves the inconvenience, expense and occasional hazard of investigation, and even surgery.

Transrectal ultrasonography in disorders of the seminal vesicles and ejaculatory ducts

Ultrasonography is an inexpensive, noninvasive, and reliable means of evaluating the integrity of the distal seminal tract. A variety of rare congenital anomalies can be demonstrated by ultrasound applied either transabdominally or by the transrectal route. Ultrasonography provides a unique insight into the function and pathology of ejaculation that may affect fertility and may well produce new diagnostic criteria to explain some of the more unusual symptoms encountered by urologists in general practice.

Staging of prostate cancer. Value of ultrasonography

Clinical staging is the attempt to determine the pathologic extent of a cancer by clinical tests (Whitmore). Traditionally, staging of prostate cancer has relied on the digital rectal examination, but ultrasonography, which provides an unprecedented picture of the gland, has become a valuable adjunct. The overall sonographic pattern helps to classify a tumor as "localized" or "extensive." A more detailed analysis yields information about the volume and location of the primary tumor; the presence, location, and extent of extracapsular extension; and the presence of seminal vesicle invasion. Comparison of sonograms with corresponding sections of radical prostatectomy specimens demonstrates that ultrasound complements the digital examination in determining by clinical tests the pathologic extent of a cancer.

Ultrasonographic changes in the normal and malignant prostate after definitive radiotherapy

As treatments for early localized prostate cancer come under closer scrutiny, the fundamental problem of documenting the success of radiotherapy becomes more obvious. Currently, no satisfactory method exists to determine tumor viability after radiotherapy. Transrectal ultrasonography is particularly valuable for monitoring the response of prostate cancer to radiotherapy. Persistent cancer retains its hypoechoic appearance after definitive radiotherapy. Hypoechoic lesions greater than 5 mm in diameter found more than 12 months after radiotherapy should be suspected of representing persistent local disease. In our study, albeit in a selected group of patients undergoing salvage radical prostatectomy, 92 per cent of such findings were associated with what we interpreted as viable tumor by light microscopy. Ultrasound-guided biopsy should be considered in such circumstances. The persistence of hypoechoic lesions in more than 65 per cent of patients 12 to 36 months after radiotherapy also suggests that local treatment failure may be underestimated by digital rectal examination and random digitally guided biopsy. Serial measurement of the diameter of hypoechoic lesions may provide a valuable indicator of progress in an individual patient. Patients with enlarging foci of tumor within the prostate after radiotherapy might be selected for biopsy and further treatment. If such a policy is employed, it is likely that a higher incidence of persistent cancer will be found after radiotherapy than has previously been discovered by random digitally guided biopsy.

Pathologic basis of the sonographic appearance of the normal and malignant prostate

The hypoechoic nature of prostatic cancer is now well recognized. In fact, not all cancers are purely hypoechoic; many are isoechoic, and some have a mixed echogenicity. Rarely, we have seen a cancer that was predominantly hyperechoic. Other signs of disturbance of the normal internal anatomy of the prostate may suggest the diagnosis of prostate cancer and are particularly valuable in assessing patients with more advanced disease. Approximately one third of early-stage cancers detected by palpation or transurethral resection are isoechoic. These tumors are anteriorly located, small, and well differentiated and infiltrate among normal glands or are composed of malignant glands similar in size to normal acini. Not all hypoechoic areas within the prostate are cancer; both normal anatomic structures and various benign conditions may appear less echogenic than the normal prostatic parenchyma. A comprehensive understanding of normal prostatic anatomy and the morphology of prostate cancer is essential to the accurate interpretation of the sonogram. Precise interpretation of prostatic sonograms requires detailed correlations of high-quality images with pathologic examinations of the whole prostate. The development of accurate criteria for the sonographic diagnosis of both malignant and benign prostatic diseases can be achieved only by such studies. As the possibilities and limitations of transrectal ultrasonography become apparent from pathologic correlation, the role of ultrasound in the diagnosis of prostate cancer will be placed on a more rational basis.

Ultrasonographic findings in prostatitis

Transrectal prostatic ultrasound is a minimally invasive, painless investigation that provides objective data on the topography of the prostate. Prostatitis is a condition difficult to diagnose in view of its varied symptomatology and lack of physical signs. The diagnosis currently rests on the finding of excessive numbers of leukocytes in the prostatic secretion obtained during the Stamey localization procedure. Seven ultrasound features having a significant correlation with a diagnosis of prostatitis have been identified: high-density and mid-range echoes, echo-lucent zones, capsular irregularity and thickening, ejaculatory duct echoes, and periurethral-zone irregularity. Ultrasonography confirms the focal nature and frequent peripheral-zone location of inflammatory prostate disease. Follow-up ultrasound studies over a short period showed that the echo-lucent zones may resolve to normal, mid-range, or high-density echoes in conjunction with a fall in the leukocyte count in expressed prostatic secretions. The ability to place a biopsy needle accurately under ultrasound control has enabled histologic assessment of the parenchymal features. The high-density echoes represent corpora amylacea; the mid-range echoes, inflammation, fibrosis, or both; and the echo-lucent zones, inflammation. The low specificity of mid-range and high-density echoes (51.9 and 40.7 per cent) and the low sensitivity (range 30.8 to 62.3 per cent) of the remaining five ultrasound features of prostatitis preclude identification of any one feature as being diagnostic of this condition. A possible exception may be the finding of echo-lucent zones, which may also prove useful in the monitoring of response to treatment. The detection of several signs within an individual's prostate suggests a diagnosis of chronic prostatitis, whereas a normal scan in a patient with symptoms of prostatitis is highly suggestive of prostatodynia.

Ultrasound-guided implantation techniques in treatment of prostate cancer

Percutaneous ultrasound-guided interstitial radiotherapy is an attractive and elegant technique for the administration of high-dose local radiotherapy to the prostate. The complications of seed implantation are those associated with the radiation rather than with the technique of implantation. However, radiotherapy has not provided impressive local control of the disease or prolonged survival. The poor disease control was not attributed to poor seed placement, but rather to the inadequacy of 125I in controlling the cancer. The essence of nonsurgical treatment for prostate cancer is the use of effective imaging. Experience in the field of minimally invasive surgery has shown that ultrasound is the ideal imaging system for targeting treatments because of its ease of use and the absence of adverse effects. As the newer techniques of implantation come to be accepted, it is hoped that the complications of rectal and bladder radiation injury will decrease and the therapeutic benefits increase. The clinical trials required to define the precise role of each of the modalities of treatment must take nodal staging into account and must be compared with the gold standard of radical prostatectomy in the treatment of early confined disease.

Radionuclide imaging of ureteric peristalsis

Dynamic renal scintigraphy is a successful and minimally invasive technique for evaluating renal function. An extension to the basic technique involving fast-frame acquisition and a modified analysis is described which enables ureteric function to be examined. Ureteric peristalsis was assessed in 32 patients using this technique. The results from 5 representative studies are described in detail. Normally functioning ureters exhibit peristaltic contractions at a frequency of up to 3/min. Hyperperistalsis that exceeds 4 contractions/min is associated with obstruction. Peristaltic behaviour in 9 patients examined before and after ESWL was not altered.

YAG laser treatment of early carcinoma of the prostate

We describe our initial experience of a method which develops the role of endoscopic surgery in the treatment of early prostatic carcinoma. An "extended" transurethral resection of the prostate (TURP) under ultrasound control reduces the prostatic tissue to a thin residual capsule suitable for subsequent transmural coagulation by endoscopic YAG laser. Twenty patients with early disease were entered into the pilot study. Three were excluded after staging (2 T0a and 1 with positive nodes on pelvioscopy-T2 N1 M0); 17 received a full course of treatment. Mean follow-up was 6 months (range 1-14). Two early patients with excessive residual tissue had initially positive biopsies and underwent second treatments with subsequently negative biopsies. Two patients continue to have positive biopsies and the rest are negative. No tumour has progressed and complications have been minimal. One patient experienced reduced frequency of erections and 1 required bladder neck incision for symptomatic bladder neck stenosis at routine follow-up endoscopy. There were no other effects on either potency or continence.

Suprapubic endoscopy: a percutaneous approach

We have assessed whether suprapubic endoscopic surgery can be helpful in situations where transurethral access is inadequate, difficult or likely to be associated with urethral damage and have applied a modified version of the well known techniques for creating and dilating a track for percutaneous renal access to the bladder. This method has been used in a series of clinical cases and in certain experimental studies. Assessment of the techniques has allowed their modification and the development of a specially designed access cannula--the St Peter's Hospital cannula.

Tissue effects of an ultrasonic scalpel for clinical surgical use

The effects of a new ultrasonic scalpel were studied in laboratory animals. Tissue heat conduction from the tip of the ultrasonic blade was measured. Tissue damage was assessed by light microscopy of histochemically stained sections. The ultrasonic scalpel incised nonfibrous tissue effectively, with minimal heat conduction, and the incisions healed with no evidence of fibrosis nor of tissue destruction.

Complications associated with ureteroscopy

A review of 125 ureteroscopies in 111 patients is reported. Eight per cent suffered major complications of perforation or stricture formation and 3% required ureteric reimplantation. Clinical follow-up and imaging studies performed more than a year after ureteroscopy produced no evidence that late complications arise.

On-table lavage to achieve safe restorative rectal and emergency left colonic resection without covering colostomy

On table orthograde colonic lavage has been used in a nearly consecutive series of 122 cases of restorative rectal resection (16 for acutely obstructing rectosigmoid lesions), and in a further 4 cases of acutely obstructing left colonic carcinoma, with the aim of both achieving safer anastomoses in these adverse circumstances and avoiding a covering colostomy. The technique was found to be safe and to be effective, only five temporary colostomies being required for management of anastomotic leakage. The incidence of clinical anastomotic leakage was 4.8 per cent.

The da Silva method of incisional hernia repair

A technique of incisional hernia repair originally devised by da Silva is described. The operation was performed on 30 patients and no recurrence was found in the 27 cases examined 1 to 4.5 (mean 2.5) years later.

The indwelling ureteric stent--the Bristol experience

Indwelling ureteric stents have been used for upper urinary tract drainage in 17 patients. The advantages over traditional methods in terms of endoscopic insertion, avoidance of external diversion and potentially lengthy periods of drainage are described. Patients requiring ureteric splintage following open procedures can also benefit from internal stenting rather than external drainage. Withdrawal is performed as a minor out-patient endoscopic procedure.

Aortic and lower extremity arterial aneurysms

A sonographic survey of 100 patients with suspected abdominal aortic, femoral, or popliteal arterial aneurysms was conducted over a period of 2 yr. Patients referred for suspected abdominal aortic aneurysms had a low incidence of associated lower extremity arterial aneurysms. Those patients referred for possible femoral or popliteal artery aneurysms frequently had multiple other peripheral arterial aneurysms. The authors recommend a survey scanning protocol in this subgroup with lower extremity aneurysms to rule out the presence of other aneurysms.