Aaron P. Perlmutter

The influence of prostate size on cancer detection

OBJECTIVESnTo determine if cancer detection rates vary with prostate size using a sextant core biopsy pattern.nnnMETHODSnWe reviewed 1021 transrectal ultrasound (TRUS)-guided sextant pattern prostate biopsies to determine if cancer detection varied based on prostate size. Prostate size was determined using a computer generated elliptical estimation method. Sextant core biopsies were taken, and the patients divided into groups based on estimated size of the prostate and biopsy outcome. Large prostates were those that were estimated by TRUS as 50 cc or more. Prostates were considered small if they were less than 50 cc. Groups were compared based on size and biopsy outcome.nnnRESULTSnAdenocarcinoma was detected in 33% (334 of 1021) of the patients. Large prostates were noted in 34% (346 of 1021), of which 23% (80 of 346) had cancer detected by sextant biopsy. Small prostates were noted in 66% (675 of 1021), of which 38% (254 of 675) had cancer detected. The difference in cancer detection in large and small glands using a sextant pattern was statistically significant (P < 0.01). Patients with positive biopsies had significantly smaller prostate sizes (40 cc +/- 26) when compared with those with negative biopsies (51 cc +/- 33) (P < 0.01). Only 14% (8 of 58) of patients with gland sizes 100 cc or greater had positive sextant biopsies while 49% (118 of 239) with prostates 25 cc or less had cancer detected. Multivariate statistical analysis was used to control for differences in age, prostate-specific antigen (PSA), PSA density, TRUS findings, and digital rectal examination between the large and small prostate groups. The difference in cancer detection persisted (P < 0.05)nnnCONCLUSIONSnCurrently no evidence exists to support differing cancer rates based on gland size alone. Our cancer detection rate using a sextant pattern was higher in men with prostates less than 50 cc, and patients diagnosed with cancer had significantly smaller prostates than those with a negative sextant biopsy. Our data suggest that significant sampling error may occur in men with large glands, and more biopsies may be needed under these circumstances. The effects of tumor volume, focality, and specimen size in relation to overall gland size may contribute to these findings.

Microwave Thermotherapy for Benign Prostatic Hyperplasia with the Dornier Urowave: Results of a Randomized, Double-blind, Multicenter, Sham-controlled Trial

OBJECTIVESnTo study the efficacy and safety of a new transurethral microwave thermotherapy device (the Urowave) in the treatment of men with clinical benign prostatic hyperplasia (BPH) in a randomized, double-blind, sham-controlled trial.nnnMETHODSnA total of 220 patients (mean age 66.2 years) with clinical BPH, an American Urological Association symptom index (AUA SI) of 13 points or more, and a peak flow rate of 12 mL/s or less were enrolled and randomized 2:1 for active versus sham treatment. All treatments were conducted as an outpatient procedure under local anesthesia, with oral sedation and analgesia only. Patients were followed up at 1 week and 1, 3, and 6 months after treatment.nnnRESULTSnThe treatments were well tolerated, and no patient received general or spinal anesthesia. The AUA SI dropped from 23.6 to 12.7 points at 6 months (P < 0.05) in the active group and from 23.9 to 18.0 points in the sham-treated group (P < 0.05, between-group difference). Statistically significant improvements were also noted for peak flow rate (7.7 to 10.7 mL/s at 6 months for active treatment, 8.1 to 9.8 mL/s for sham treatment, P < 0.05, between-group difference) and for average flow rate. A decrease in AUA SI of more than 30% was achieved in 72% versus 38% of patients (active versus sham treatment, respectively) and more than 50% in 50% versus 19% of patients. In general, active Urowave-treated patients perceived a lot of improvement, whereas sham-treated patients perceived a little to some improvement. More of the actively treated patients had dysuria and urgency after treatment, and ejaculatory dysfunction (e.g., hematospermia) was more common in actively treated patients as well. Secondary urinary retention after removal of the catheter occurred in 8 patients (5.4%).nnnCONCLUSIONSnThe Dornier Urowave transurethral microwave thermotherapy device for treatment of clinical BPH is effective in decreasing symptoms and bother and improving quality of life and flow rate and is superior to sham treatment. Patients perceive a great deal of improvement, independent of their baseline symptom severity. Adverse events are in general transient and mild in nature. Extended follow-up is necessary to document long-term durability of improvements.

Demographics, family histories, and psychological characteristics of prostate carcinoma screening participants

The goals of this study were to 1) understand the reasons that men seek prostate carcinoma screening, in light of the ongoing medical controversy surrounding screening; and 2) assess the level of psychological distress and perceived risk among men seeking screening, and whether or not these variables were dependent on a mans family history of prostate carcinoma.

Heat treatment for severe, symptomatic prostatic outflow obstruction

SummaryA pilot study was undertaken using the Prostathermer, the Primus and the Thermex-II devices to treat a total of 48 patients with proven outflow tract obstruction. All patients showed severe obstruction and had a mean pre-treatment flow rate of 8.8 ml/s and a mean post-micturition residual urinary volume of 120 ml. The mean symptomatic score (Madsen-Iverson score) was 14. When all three treatment groups are considered as one, the post-treatment flow rate improved to 11.1 ml/s. The post-micturition residual urinary volume fell to 46 ml and the mean symptom score fell to 8. Follow-up involved only a maximum of 12 months, but during this time only four patients in the group agreed to undergo a prostatectomy and 88% of the group were considered to have insufficient symptoms to warrant prostatectomy, although all of the patients were considered to be candidates for prostatectomy prior to treatment. The treatment is discussed in the light of the literature on placebo response in prostatic outflow obstruction.

Acute and chronic interstitial cryotherapy of the adrenal as a treatment modality.

Abstract Adrenalectomy is indicated for patients with large adrenal lesions or functional tumors. Cryoablation is currently used as a surgical alternative for the treatment of prostate, lung, brain, pharynx, and liver tumors. The purpose of this study was to determine if cryosurgery could be delivered to small areas in the adrenal gland in a controllable and reproducible manner such that tissue could heal in a nonpathologic way. A total of 14 female mongrel dogs underwent acute (n =u20098) or chronic (4 weeks, nu2009=u20096) cryoablation using the Cryounit. In the acute study using an open transabdominal approach a 2-mm cryoprobe was placed interstitially into the adrenal tissue, whereas 0.032-inch thermocouples were cannulated into the ipsilateral adrenal artery and vein. Adrenal parenchymal temperature changes were measured using 0.032-inch thermocouples placed at 0.4- and 0.8-cm intervals from the cryoprobe. In the chronic study, cryoablation was achieved by transperitoneal laparoscopic access using a standard laparoscopic technique. Interstitial cryoprobe temperatures decreased from 33.1u2009±u20091.9u2009°C to −148u2009±u20091.2u2009°C following 15u2009min of freezing in the acute study. Cryoablation of adrenal tissue achieved temperatures of −41.8u2009±u20095.7u2009°C and −21.8u2009±u20091u2009°C at distances of 0.4 and 0.8u2009cm from the cryoprobe, respectively. There was no significant change in adrenazl artery or vein temperatures during cryoablation. Histologically there is a clear demarcation between viable and nonviable tissue characterized by areas of multifocal hemorrhage and pyknosis. After 4 weeks of healing a well-defined line of necrotic and viable tissue is visible. Cryoablation of the adrenal can be delivered in an effective, controllable, and reproducible manner. This controllable energy form may provide a new treatment modality for tissue destruction where adrenal gland preservation is necessary and can be performed by the laparoscopic approach. Understanding the effect of adrenal cryoablation may allow us to treat selected patients with small tumors where organ preservation is necessary.

Prostatic Heat Treatments for Urinary Outflow Obstruction

A nonrandomized pilot study was done of 139 patients with symptomatic benign prostatic hyperplasia treated with 3 prostatic heating devices. Of the patients 19 underwent transrectal hyperthermia with the Biodan Prostathermer and in 15 the Primus Prostate Machine was used. At 2 1/2 years 7 of 19 patients (37%) patients in the Prostathermer group and 6 of 15 (40%) in the Primus group had adequate sustained improvement and had not undergone further treatment. At 1 year 55 of 100 patients (55%) treated with the Thermex-II section transurethral thermotherapy unit had a satisfactory result, with 40 (40%) having undergone transurethral resection of the prostate. The number of patients who failed therapy increased with each followup. Analysis of pretreatment parameters, including patient age, prostate size, peak urinary flow rate, post-void residual urine volume and symptom score, did not predict a successful outcome. Although these devices have minimal effect on peak urinary flow rate, a subset of patients enjoy symptomatic improvement.

Transrectal hyperthermia in the benign painful prostate

SummaryTransrectal hyperthermia was used to treat 11 patients with prostatic pain of benign origin. Temperatures of between 42° and 43°C were used during six treatments lasting 60 min each. Pre-treatment flow rates were erratic in nine patients. Following treatment, nine showed significant subjective improvement and one exhibited minimal improvement; this was associated with normalisation of the flow rate pattern in seven of nine cases. The mean peak urinary flow rate increased from 14.7 to 19.1 ml/s. In five subjects the response was maintained for a mean of 12 months. Relapse was associated with a return to an erratic flow pattern showing a reduced peak flow. No complications were experienced.

LASER-TISSUE INTERACTIONS DURING LASER PROSTATECTOMY

N eodymium:YAG laser prostatectomy is an effective and safe surgical treatment for benign prostatic hyperplasia. The tissue changes that occur during lasing can be recognized by the surgeon, so that technique can be optimized to create the desired result. In the clinical images presented here, the terms coagulation, ,vaporization, and carbonization are defined and depicted. Tissue coagulation results when tissue is heated to between 60 ° and 100°C. Cell death occurs secondary to protein denaturation, which destroys cellular structural integrity (Fig. 1). Coagulated tissue appears white in color. At the time of lasing, no tissue is removed. Tissue loss occurs as a result of sloughing over a period of several weeks or months.