Prostate cancer screening at an equal access tertiary care center: its impact 10 years after the introduction of PSA

INTRODUCTION AND OBJECTIVES

Dwight D. Eisenhower Army Medical Center has been involved in Prostate Cancer Awareness Week (PCAW) screening during the period 1995-2000. The purpose of this study is to review the results of screening in a self-selected population of military beneficiaries at our institution.

MATERIALS AND METHODS

Screening involving a brief urologic history, digital rectal examination (DRE) and serum prostatic specific antigen (PSA) measurement was offered to our screening population. Patients with an elevated PSA (>4.0 ng/ml) and/or a suspicious DRE were considered for transrectal ultrasonography with prostate needle biopsy (TRUS/PNB). Patient health records were reviewed retrospectively and analyzed to determine patient demographic characteristics, PSA distribution, DRE results and cancer detection rates.

RESULTS

A total of 455 screening visits were performed from 1995 to 2000, of which 426 visits were included for analysis. Mean age of the study population was 57.4 y (40-83). Seventy-one percent of the patients reported prior PSA screening visits. Forty-four patients met indications for biopsy. A total of 30 TRUS/PNB were performed demonstrating presence of cancer in three patients for an overall cancer detection rate of 0.7%.

CONCLUSIONS

Our study shows that the overall prostate cancer detection rate at our institution is lower than detection rates previously reported in the literature. Potential reasons for this finding may include that the subjects participating in PCAW screening tended to be younger than in other series and that a majority of them had already undergone prior screening. These findings suggest the need to modify prostate cancer screening recommendations and to improve prostate cancer screening efficacy.

Managing the nondeflating urethral catheter

BACKGROUND

Urethral catheterization is a routinely performed procedure in hospitalized patients. Numerous complications have been reported secondary to urethral catheter placement.

METHODS

The medical literature was searched using the following key words: "urethral catheter," "complications," and "management." A case report is described and a review of the literature is provided to assist in managing the nondeflating urethral catheter balloon.

RESULTS AND CONCLUSIONS

All physicians who order urethral catheters must be aware of the possibility of a nondeflating catheter balloon and be comfortable with its initial management. The literature has an abundance of techniques for managing the nondeflating urethral catheter balloon. The approach and algorithm provided serve as a guide for the management of this complication by the family physician.

Home flow rates in evaluation of lower urinary tract symptoms in men

We wanted to determine if 5-second home flow rates can be used in the evaluation in men with lower urinary tract symptoms (LUTS). Fifty previously untreated men with LUTS were evaluated by history and physical examination, international prostate symptom score (IPSS) questionnaire, and two methods of uroflowmetry. Each participant underwent three formal uroflow measurements using the Dantec UD5500 Mk2 machine and subjective 5-second home uroflow measurements twice daily for 7 days. The reliability of each test as well as correlation coefficients between the two methods of uroflowmetry were determined. The reliability for the average of the 14 home flow rates was 0.99 and the reliability for any single home flow was 0.82. Reliability for the average of three uroflows in measuring Qmax, Qave, flow times, and volume are 0.91, 0.91, 0.86, and 0.79, respectively. If single measurements are used, the values are 0.77, 0.78, 0.68, and 0.56. Home flow average is significantly different from Qmax and Qave (p < .001). No significant correlation was found between any of the uroflowmetry measurements or home flow average and IPSS or bother score. Home flows rates and uroflowmetry are reliable tests. There is a weak correlation between average home flows and Qmax and Qave. The greatest use of home flow rates probably lies in follow-up of patients who had either medical or surgical intervention for LUTS.

A novel technique to prevent Foley catheter loss following radical retropubic prostatectomy

We describe a method to prevent Foley catheter loss following radical retropubic prostatectomy. In 84 consecutive patients undergoing radical retropubic prostatectomy, a technique of securing the indwelling Foley catheter extracorporeally using a permanent stitch and a sterile button was utilized. No instances of unintended Foley catheter dislodgment were experienced in any of the 84 cases. The extracorporeal button was well tolerated by all patients, and there was no increased incidence of catheter-related complications. This technique provided the additional benefit of balloon volume adjustment in ten patients who experienced bladder spasms. This method is a simple, safe and well-tolerated adjunct to avoid Foley catheter loss following radical retropubic prostatectomy.

The use of an external vacuum device to augment a penile prosthesis

Although penile prostheses are highly effective in the treatment of erectile dysfunction, a small percentage of patients are dissatisfied. Serendipitously, a patient in this group found that using an external vacuum device to augment his prosthetic erection provided a dramatic objective improvement in his erection and increased his overall satisfaction with intercourse. Patients who had tried the combination of external vacuum device and penile prosthesis simultaneously were identified from our penile prosthesis population as well as the Osbon Medical Systems database. Telephone interviews were conducted to determine efficacy, satisfaction, and side effects from the combination. Twelve patients completed the telephone survey. Four patients had semirigid and eight had inflatable penile prostheses. After using the vacuum device to augment the erection, all reported increased rigidity and patient/partner satisfaction, and 11 of 12 described improved length and girth. Minimal complications were noted. Concomitant use of an external vacuum device and penile prosthesis was safe in this select population. The combination may be indicated in patients with penile prostheses who are dissatisfied with size and/or rigidity, and in those who refuse or who are poor candidates for prosthesis revision.

Intracavernosal drug-induced erection therapy versus external vacuum devices in the treatment of erectile dysfunction

OBJECTIVES

To determine if there is a significant difference between intracavernosal self-injection and external vacuum devices when compared directly for satisfaction, effectiveness and side-effects.

PATIENTS AND METHODS

Fifty men were randomised into two groups and received either instruction on the use of the Osbon ErecAid system or self-injection therapy. After 15 uses, each group completed a questionnaire detailing efficacy, satisfaction and side-effects, and then changed to the other modality after appropriate instruction. A questionnaire was completed by study participants and their sexual partners after using both methods. Patients were followed for 18-24 months using telephone interviews.

RESULTS

Forty-four patients (mean age 62.3 years, range 38-84) completed the study. Patients and their partners reported a superior quality of erections with the injection method but the difference did not reach statistical significance. The ability to attain orgasm and the overall satisfaction of the patient and partner with the sexual experience was significantly better when using injections. Side-effects were similar between the modalities. Subgroups analysed for age, duration and aetiology of impotence showed that younger patients (< 60 years), those with a shorter duration of impotence (< 12 months) and those impotent secondary to radical prostatectomy strongly favoured injection therapy (P < 0.05). Overall, of the 44 couples, the final preferences of the patients were 25 (57%), 12 (27%), six (14%) and one (2%) for the injection, vacuum device, both or neither, respectively, and of the partners were 22 (50%), 12 (27%), six (14%) and four (9%), respectively. At 18-24 months, 80% of patients were still using either the vacuum device, injections, or both.

CONCLUSION

Both the vacuum device and injections are effective treatment modalities for impotence and are associated with good long-term success. Overall, there was a trend favouring injection therapy over the vacuum device which was most significant in younger patients, those with a shorter duration of impotence, and those impotent secondary to radical prostatectomy.

A comparison of intermittent pneumatic compression of the calf and whole leg in preventing deep venous thrombosis in urological surgery

PURPOSE

Intermittent pneumatic compression of the calf and/or thigh effectively decreases the incidence of deep venous thrombosis and other thrombotic sequelae but clinical data comparing these modalities are currently lacking.

MATERIALS AND METHODS

A total of 90 patients undergoing major urological surgery was randomly assigned to receive calf length or thigh length pneumatic compression for antithrombotic prophylaxis. Duplex ultrasound of the lower extremities was performed preoperatively and twice postoperatively to evaluate for deep venous thrombosis. Health care providers in the operating room, recovery room and ward were asked to compare the compression systems, and a cost analysis was performed.

RESULTS

A total of 47 patients wore the thigh length sequential pneumatic sleeves and 43 wore calf length uniform compression systems. A pulmonary embolus without evidence of deep venous thrombosis was detected in 1 patient (2%) using the thigh length system. A thrombus was detected in the common femoral vein by duplex ultrasonography in 1 patient (2%) with the calf length system. Nursing personnel found the calf length sleeves easier to apply and more comfortable by patient account but they were satisfied with both systems. There was a significant cost savings with the calf length pneumatic compression system.

CONCLUSIONS

Calf and thigh length pneumatic compression systems similarly decrease the risk of deep venous thrombosis in patients undergoing urological surgery. The calf length system has the added advantage of being less expensive and easier to use.

Bilateral renal cell carcinoma in autosomal dominant polycystic kidney disease. A case report and literature review

The association of autosomal dominant polycystic kidney disease with renal cell carcinoma is infrequent. A case of bilateral renal cell carcinoma in conjunction with autosomal dominant polycystic kidney disease is presented. The discussion emphasizes pertinent diagnostic and therapeutic considerations.

Erectile dysfunction following transurethral resection of the prostate

PURPOSE

We objectively measured the incidence of erectile dysfunction following transurethral resection of the prostate.

MATERIALS AND METHODS

A total of 56 men completed a questionnaire detailing perceived sexual dysfunction, and underwent nocturnal penile tumescence testing for 3 nights before transurethral resection of the prostate and again at 3 months postoperatively.

RESULTS

Complete data were available for 40 men. No significant difference was found in penile tumescence, number of erectile events and duration of events before and after surgery. Preoperative and postoperative rigidity was statistically different, with a slight improvement after transurethral resection of the prostate (p < 0.05). A subjective decrease in quality of erection after transurethral resection of the prostate was reported in 27.5% of the patients. However, on further questioning, 63.6% of these patients equated retrograde ejaculation with decreased potency.

CONCLUSIONS

We demonstrated no decrease in objective parameters of erectile function studies following transurethral resection of the prostate. Previous estimates of impotence after transurethral prostatectomy may have been tainted by subjective patient reports equating retrograde ejaculation with erectile dysfunction.

Neoadjuvant hormonal therapy in the management of prostate cancer: a surgical and radiation therapy review

Neoadjuvant hormonal therapy (NHT) prior to radical prostatectomy is an old concept that has recently been revisited. First described in the 1940s as a method to downstage inoperable prostate cancer prior to perineal prostatectomy. NHT fell out of favor for several reasons: the side effects of estrogen therapy, the finality of orchiectomy, improved staging methods, and newer treatment strategies for prostate cancer, including external beam and interstitial radiation therapy. Contemporary interest in NHT has resurfaced primarily due to the introduction of well-tolerated reversible androgen blockade. High cause-specific survival rates following radical prostatectomy for organ confined disease are possible, yet the disturbingly high incidence of positive margins in current radical prostatectomy series led to interest in offering NHT to patients prior to radical prostatectomy to impact on the positive margin rate. Initial nonrandomized studies showed that NHT provided a substantial decrease in prostate size and PSA level in addition to reducing positive margin rate by an uncertain mechanism. Subsequently, controlled randomized studies have been performed, the majority of which have confirmed decreased margin positivity. NHT has been incorporated successfully into external beam radiotherapy for locally advanced prostate cancer as well. Significantly improved disease control is possible when hormones are combined with radiation therapy. The favorable outcome of this radiation therapy approach has led to the approval of flutamide (Eulexin) for this indication when combined with a luteinizing hormone-releasing hormone analogue or orchiectomy. Whether these initial results will ultimately affect recurrence and survival data is unknown. This article provides a comprehensive review of the world literature on NHT: from an historical prospective to the current state of the art for both radical prostatectomy and external beam radiation therapy.

Renal cell carcinoma in cadaver donor kidney

A cadaver kidney, reported to contain a "simple cyst," was received from another institution. Frozen section biopsy prior to transplant showed renal cell carcinoma. The contralateral kidney already had been transplanted at the other medical facility.

Monitoring of suspected infertile men with varicocele by the sperm penetration assay

Although varicocele remains the most frequently diagnosed cause of male infertility, and improvement in semen quality is associated with repair of varicocele, improvement in spermatozoal fertilizing capacity has not been conclusively demonstrated. The sperm penetration assay was employed to monitor prospectively surgical (n = 59) and nonsurgical (n = 40) groups of men with varicocele. There were no significant increases in the average count, motility, morphologic features, or sperm penetration assay results for either group. Varicocele surgery enhanced assayable egg penetration rates in 14 of the 59 patients (23.7%), whereas the nonsurgical group had 10% spontaneous improvement. Of those in the surgery group who showed assayable fertility enhancement and were attempting conception, pregnancies were achieved in 70% (7 of 10 patients). Of patients in the nonsurgical group who improved in the assay, no pregnancies were obtained.

Nonpsychotic genital self-mutilation

The case of a sixty-four-year-old man who progressively created a penoscrotal hypospadias on himself is presented. Although genital self-mutilation is normally considered symptomatic of deep psychotic disturbance, the details and evaluation of this case would classify it as nonpsychotic, though unusual behavior.

Comparison of the penetration ability of human spermatozoa into bovine cervical mucus and zona-free hamster eggs

In vitro bovine cervical mucus (BCM) penetration tests, sperm penetration assays (SPA) using zona-free hamster eggs, and routine semen analyses were performed on a total of 136 freshly collected semen samples from men who were seen at an infertility clinic. The correlations between bovine cervical mucus penetration and other semen parameters were the percent motile spermatozoa (r = 0.48), progressive motility grade (r = 0.44), sperm count (X 10(6)/ml) (r = 0.47), the percent normal morphology (r = 0.32) and the percent eggs penetrated (r = 0.46) (P less than 0.0001 for each correlation coefficient). When known fertile (n = 32) and infertile (n = 18) groups were tested, positive mucus penetration was associated 75% correctly and positive egg penetration was associated 90% correctly to clinical status. The mucus test had no false-negative results and the SPA had no false-positive results in these groups. It appears, then, that the mucus test and sperm penetration assay, although contributing different elements of data to an infertility evaluation, are both useful adjuncts to a semen analysis.

Variability in the human-hamster in vitro assay for fertility evaluation

Sources of variability in the zona-free hamster egg penetration assay were evaluated. Internal consistency in the assay was examined in replicate experiments using sperm from 23 donors. The average difference in the percentage of fertilization between the replicates was 3.9%. Optimal preincubation conditions and insemination time were examined and shown to be 0.5 to 1.0 X 10(7) sperm/ml and 2 to 3 hours. Abstinence time was found to be a variable, and a critical abstinence of more than 12 hours was required. Prolonged exposure to seminal plasma (i.e., more than 30 minutes) produced a reduction in the fertilization test results. If the variables studied here are consistently controlled, then changes in the assay results greater than the experimental error should reflect true changes in the semen sample.

In vitro fertilization rates after varicocele repair

Causal relationship of varicocele to infertility is controversial. Studies of hormonal milieu, semen and testicular tissue yield data of debatable significance. We herein assay the fertilizing ability of men with varicocele and monitor changes consequent to surgical correction of varicocele. Zona-free hamster ova were used to determine fertilizing ability. A fertilization rate of less than 10 per cent correlates with infertility. Between May 1978 and November 1979, 75 men with varicocele presenting for fertility evaluation and 23 men with painful varicocele were tested. Of the patients infertile clinically and by in vitro fertilization assay 42 elected ligation of the internal spermatic vein(s). Average fertilization rate of the painful varicocele group was 20.5 per cent and for the infertile group it was 1.2 per cent. Average fertilization rates postoperatively in the infertile group were 2.9 per cent (3 months), 7.7 per cent (6 months), 2.8 per cent (9 months), 7.8 per cent (12 months), 17.5 per cent (15 months) and 8.0 per cent (18 months). Pregnancies occurred only in partners of men whose fertilization rates were between 2.9 and 8.3 per cent preoperatively and who improved to greater than 10 per cent postoperatively. The in vitro fertilization assay may help select those individuals with varicocele and infertility most likely to benefit from varicocele repair.

Per os pubis (POP) urethropexy

This series of 24 female patients with stress urinary incontinence managed surgically by a pubis-pubovaginal fascia fixation demonstrates success comparable or superior to other techniques. Several advantages in carefully selected patients are noted.

Colocutaneous fistula: an unusual complication of retroperitoneal lymphadenectomy

The unusual complication of colocutaneous fistula following retroperitoneal lymphadenectomy for testis tumor is presented. Etiology, management and prevention are emphasized.

Renal actinomycosis

Renal actinomycosis is an endogenous systemic fungal disease with rare renal involvement. Diagnosis, pathogenesis, and therapy are discussed.

"Acute scrotum" in Henoch-Schönlein syndrome

Two patients with Henoch-Schönlein syndrome presented with clinical pictures mimicking testicular torsion. No evidence of testicular torsion was found. A review of the literature revealed that testis torsion is very rarely associated with testicular involvement in Henoch-Schönlein syndrome, and hence only rarely is surgical exploration required.