Alaa Meshref

Importance of Additional “Extreme” Anterior Apical Needle Biopsies in the Initial Detection of Prostate Cancer

OBJECTIVES To describe our experience of adding extreme apical cores in men undergoing initial biopsy. Prostate cancer detection efforts have focused on increasing the number of cores. A more significant factor, however, may be their location. Laterally directed and apical cores have been associated with the highest cancer detection rate, especially the apical cores for men undergoing repeated biopsies. METHODS A prospective trial was conducted between September 2007 and April 2009. A total of 181 men with increased prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE), or both, underwent an initial transrectal ultrasound-guided biopsy (TRUS-BX). All patients underwent a standard 12-core biopsy scheme plus 2 additional cores taken from the extreme anterior apex, defined as the site immediately lateral to the junction of apex and urethra. Each core was marked by a special colored ink for identification. Site-specific detection and tumor characteristics were reported. RESULTS Prostate cancer was detected in 86 patients (47.5%). The apical cores (3 on each side) achieved the highest cancer detection rate (73.6% of all cancers), and the additional extreme anterior apical cores (1 on each side) achieved the highest rate of unique cancer detection (P = .011). CONCLUSIONS From our experience, the apical cores, especially the extreme apical cores, increase prostate cancer detection on initial TRUS-BX and minimize the potential for misdiagnosis and need for repeat biopsy.

Rising incidence of acute prostatitis following prostate biopsy: fluoroquinolone resistance and exposure is a significant risk factor.

OBJECTIVE To evaluate the frequency and potential risk factors for infection-related complications after transrectal prostate biopsy and to propose adjustments in current antimicrobial prophylaxis recommendations. METHODS During 2008-2010, 107 patients underwent transrectal ultrasound-guided biopsies of the prostate at our institution. Charts were reviewed for infection-related complications within 30 days of the procedure. Potential risk factors were evaluated, including age, diabetes mellitus, chronic constipation/diverticular disease, prior use of quinolones, enema and prostatitis, on the pathology report. For patients with acute prostatitis, urine and blood samples were assessed for bacteriology and antibiotic susceptibility. RESULTS Of our 107 patients, acute prostatitis developed in 10 (9.3%). The most significant risk factor was prior use of a fluoroquinolone antimicrobial, with acute prostatitis developing in 7 (17.1%) of 41 patients who had used a fluoroquinolone compared with 3 (4.5%) of 66 patients who had not (P=.042). Patients who received an enema before the procedure were slightly less likely to develop prostatitis (P=.061). Of 8 positive specimens, the organisms isolated were Escherichia coli in 6, Klebsiella pneumoniae in 1, and Staphylococcus epidermidis in one. Isolated Gram-negative organisms were fluoroquinolone-resistant in 85.7% of samples. CONCLUSION Prior fluoroquinolone intake is a significant risk factor behind a rising incidence of acute prostatitis after transrectal prostate biopsy. Identified pathogens are mostly Gram-negative organisms with a high rate of fluoroquinolone resistance. Alternative prophylaxis regimens for the biopsy procedure should be considered in patients with recent quinolone intake.

Management of ureteral stones by extracorporeal shock wave lithotripsy using Lithostar lithotriptor.

In 282 patients 290 ureteral stones were treated with extracorporeal shock wave lithotripsy using the Lithostar lithotriptor. Stones were in the upper ureter in 198 units (68.3%), middle ureter in 36 (12.4%) and lower ureter in 56 (19.3%). The average stone mass was 11.9 mm. and the mean number of shock waves was 4,913 for all levels with a mean kv. of 16.9. The average number of sessions was 1.5 for all sites. Auxiliary measures in the form of ureteral catheterization were done in 24 patients (8.5%) and internal stenting in 12 (4.25%), all of whom had upper or middle ureteral stones. Disintegration of the stones was achieved in 99% of the upper, 93.7% of the middle and 91.7% of the lower ureteral stones. However, clearance of fragments within 3 months from the last session was achieved in 94.8% of the upper, 87.5% of the middle and 91.7% of the lower ureteral stones for an overall stone-free rate of 93.3%.

Holmium Laser Enucleation of the Prostate: Initial Report of the First 230 Egyptian Cases Performed in a Single Center

OBJECTIVES To report our experience with the first 230 cases of holmium laser enucleation of the prostate (HoLEP) performed in a single center. METHODS A total of 230 cases of HoLEP were performed between June 2007 and June 2008. Mean age of patients was 69.8 +/- 10.3 years, and 21.3% of patients were either on anticoagulant or antiplatelet treatment. There was no limit for prostate size, with a mean prostate size of 86.5 +/- 65.4 g (range: 20-350 g). Follow-up was performed regularly at 1, 3, 6, and 12 months, assessing the Q(max), PVR, and International Prostate Symptom Score. RESULTS Weight of prostate chips retrieved after morcellation was 78.6 +/- 61.3 g (range: 10-350), with enucleation time 102.2 +/- 55.4 minutes and morcellation time 19.3 +/- 10.1 minutes, leading an estimated efficiency rate of 0.64 g/min. The rate of decrease in prostate volume and prostate-specific antigen was 90.8% and 82.5%, respectively. At 1 month, mean Q(max) increased from 7.7 +/- 2.3 to 25.8 +/- 10.1 mL/s (P <or=.001), mean PVR decreased from 171.3 +/- 126.3 to 41.6 +/- 45.7 mL (P <or=.001), and mean international prostate symptom score improved from 17.3 +/- 6.7 to 6.6 +/- 3.4 (P <or=.001). These improvements were sustained throughout a 12-month follow-up period. Temporary irritative symptoms were evident in 34.6% and stress urinary incontinence in 9%, both of which were self-limited on medical treatment and Kegel exercises, respectively. Only 1 patient with pancytopenia required blood transfusion and there was no case for transurethral resection syndrome. CONCLUSIONS HoLEP is a safe and an effective modern modality for the treatment of symptomatic BPH regardless of the gland size, with satisfactory clinical outcome.

Modified extravesical ureteral reimplantation technique for kidney transplants

PurposeWe describe a modification and evaluate a technique of extravesical ureteral reimplantation for kidney transplant.Materials and methodsWe reviewed the records of 120 kidney transplant recipients who underwent ureteral reimplantation via a modified extravesical technique. Follow-up evaluation included renal ultrasonography. Because reflux is not routinely assessed in transplant cases, only symptomatic reflux was considered a complication and accessed with voiding cystourethrography (VCUG). The urological complications evaluated included urinary fistula, ureteral stenosis and symptomatic vesicoureteral reflux.ResultsThe modified extravesical technique produced a successful result in 93.4% of patients with no symptomatic reflux or anastomotic obstruction. Anastomotic complications included stenosis in four patients, prolonged leakage and fistula in three patients, and symptomatic vesicoureteral reflux in one patient. Other urologic complications included complicated hematuria in three patients, postoperative urosepsis in one patient, and ureteral stenosis caused by extrinsic compression in three patients due to lymphocele (two patients) and by adhesions (one patient).ConclusionsThe modified extravesical ureteral reimplantation is a reliable procedure with predictable results comparable to those of more-traditional techniques and proved to be efficient without increasing the incidence of urological or anastomotic complications. This modified technique offers two advantages; removal of the ureteral stent with the urethral catheter without the need for a postoperative cystoscopy and facilitation of postoperative endoscopic maneuvers if needed.

Population-based patterns of radical retropubic prostatectomy use.

OBJECTIVES To examine the use of radical retropubic prostatectomy (RRP) in a large population-based study. METHODS Identification of all RRPs performed in the province of Quebec between the years 1988 and 1993 was accomplished by relying on the Quebec Healthcare Plan Database. RESULTS Overall, 2861 RRPs have been performed during the study period. On average, 80% of surgeries have been performed by urologists using this surgery 12 times or less annually. Of all surgeries, 420 (15%) RRPs have been performed in individuals 71 years of age or older. CONCLUSIONS Each year, most RRPs (80%) in this population-based study were performed by urologists performing this procedure 12 times or less annually. A substantial proportion (15%) of RRPs have been performed in men 71 years of age or older, in whom the detriments of radical surgery may outweigh its benefits. These findings could potentially contribute to suboptimal outcomes when radical prostatectomy is compared with alternative treatment modalities.