Brian Saltzman

Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia

OBJECTIVES Prostate-specific antigen (PSA) is produced exclusively in the prostate gland and is currently the most useful clinical marker for the detection of prostate cancer. In this report, we examine whether serum PSA is also a predictor of important benign prostatic hyperplasia (BPH)-related outcomes, acute urinary retention (AUR), and the need for BPH-related surgery. METHODS Three thousand forty men were treated with either placebo or finasteride in a double-blind, randomized study of 4-year duration. Serum PSA was measured at baseline, and baseline prostate volume was measured in a 10% subset of 312 men. Probabilities and cumulative incidences of AUR and BPH-related surgery, as well as reduction in risk of events with finasteride, were calculated for the entire patient population, stratified by treatment assignment, baseline serum PSA, and prostate volume. RESULTS The risk of either needing BPH-related surgery or developing AUR ranged from 8.9% to 22.0% during the 4 years in placebo-treated patients stratified by increasing prostate volume and from 7.8% to 19.9% when stratified by increasing serum PSA. In comparison with symptom scores, flow rates, and residual urine volume, receiver operating characteristic curve analyses showed that serum PSA and prostate volume were the most powerful predictors of spontaneous AUR in placebo-treated patients (area under the curve 0.70 and 0.81, respectively). Finasteride treatment reduced the relative risk of needing surgery or developing AUR by 50% to 74% and by 43% to 60% when stratified by increasing prostate volume and serum PSA, respectively. CONCLUSIONS Serum PSA and prostate volume are powerful predictors of the risk of AUR and the need for BPH-related surgery in men with BPH. Knowledge of baseline serum PSA and/or prostate volume are useful tools to aid physicians and decision makers in predicting the risk of BPH-related outcomes and choosing therapy for BPH.

ACCURATE DETERMINATION OF CHEMICAL COMPOSITION OF URINARY CALCULI BY SPIRAL COMPUTERIZED TOMOGRAPHY

PURPOSE Choice of efficacious clinical management of symptomatic renal calculi can be facilitated by ascertaining the precise chemical composition of the calculus. Spiral computerized tomography (CT) is becoming a frequently used radiographic examination to establish the diagnosis and severity of calculus disease. Our objective for this study was to determine the precision of spiral CT in identifying the chemical composition of 6 different types of urinary calculi with region of interest measurements using spiral CT. MATERIALS AND METHODS A total of 102 chemically pure stones were separated into 6 groups. The stones along with phantoms containing butter (fat) and jello (water) were mounted vertically in the scanner gantry. Then 1 mm. thickness scanning was performed with a high speed scanner at the 2 energy levels of 80 and 120 kV. The determination of the chemical composition was performed using the absolute CT value measured at 120 kV. and the dual kilovolt CT values measured at 80 and 120 kV. Hounsfield unit at 80 kV.-Hounsfield unit at 120 kV.). RESULTS The absolute CT value measured at 120 kV. was able to identify precisely the chemical composition of uric acid, struvite and calcium oxalate stones. It was imprecise in differentiating calcium oxalate from brushite stone and struvite from cystine stone. However, dual kilovolt CT value was able to differentiate these latter stones with statistical significance (p < 0.03). Uric acid stones were easily differentiated from all other stones using the absolute CT value. CONCLUSIONS This study demonstrates that the chemical composition of urinary calculi can be accurately determined by CT scanning in an in vitro setting.

Clinical manifestations of classical, endemic African, and epidemic AIDS-associated Kaposi's sarcoma

Kaposis sarcoma, first described in 1972, is a rare, chronic neoplasm that occurs most often in elderly men of Eastern European origin. In the mid-twentieth century, more aggressive forms of Kaposis sarcoma were found to be an endemic disease especially common among young black men in central Africa. Kaposis sarcoma also occurs in iatrogenically immunosuppressed patients, such as kidney transplant recipients. In 1981, the sudden occurrence of an unusual, disseminated form of Kaposis sarcoma in homosexual men in New York and California heralded the epidemic now known as the acquired immunodeficiency syndrome (AIDS). Ninety-five percent of all AIDS-associated Kaposis sarcoma (AIDS-KS) has been in homosexual men; however, the incidence of AIDS-KS has diminished from greater than 40% of men with AIDS since 1981 to less than 20% in 1989. The remaining 5% of AIDS-KS has been seen in all other populations at risk for AIDS. The reasons for the remarkable persistent increased prevalence of AIDS-KS among homosexual men remains obscure. Clinically, AIDS-KS is a highly varied neoplastic disease characterized by multifocal mucocutaneous lesions often with lymphatic and visceral involvement. The etiology of Kaposis sarcoma remains unknown although various hypotheses have been suggested, including endothelial-tumor growth factors, oncogenic expression, genetic predisposition, and environmental cofactors. An as-yet unidentified viruslike agent has been proposed as a possible direct cause of this neoplasm. Different treatment modalities for Kaposis sarcoma have been employed with varying success, these include localized radiation therapy, cryotherapy, electrocauterization, surgical excision, and a variety of systemic chemotherapeutic regimens, as well as alpha-interferon. Although all available treatments help control the lesions, none lengthens survival.

Storage (Irritative) and Voiding (Obstructive) Symptoms as Predictors of Benign Prostatic Hyperplasia Progression and Related Outcomes

OBJECTIVES To assess the utility of voiding and filling symptom subscores in predicting features of benign prostatic hyperplasia (BPH) progression, including acute urinary retention (AUR) and prostate surgery. METHODS The Proscar Long-term Efficacy and Safety Study (PLESS) was a 4-year study designed to evaluate the effects of finasteride versus placebo in men with lower urinary tract symptoms (LUTS), clinical evidence of BPH, and no evidence of prostate cancer. A self-administered questionnaire was employed to quantify LUTS at baseline. Receiver operating characteristics (ROC) curves were used to assess baseline characteristics from patients treated with placebo as predictors of outcomes. The characteristics assessed included the overall symptom score (Quasi-AUA SI), separate voiding and filling subscores, prostate volume (PV) and serum prostate-specific antigen (PSA) levels. RESULTS PV and PSA were superior to the symptom scores at predicting episodes of spontaneous AUR and all types of AUR. The Quasi-AUA SI and the filling and voiding subscores were effective at predicting progression to surgery; however, PSA was more effective at predicting this outcome. To better evaluate symptoms as predictors of surgery, patients who experienced a preceding episode of AUR were excluded from the surgery analysis. In the absence of preceding AUR, the best predictors of future surgery were the Quasi-AUA SI and the filling subscore. CONCLUSIONS Among men with LUTS, clinical BPH and no history of AUR, the overall symptom score and storage subscore are useful parameters to aid clinicians in identifying patients at risk for future prostate surgery. PV and PSA were the best predictors of AUR, while PSA was the best predictor of prostate surgery (for all indications).

Characteristics of bladder leiomyoma as noted on magnetic resonance imaging

Leiomyoma of the bladder is a rare benign mesenchymal tumor that can be evaluated preoperatively with magnetic resonance imaging. Small tumors that appear to be leiomyomas on magnetic resonance imaging can be treated conservatively with transurethral resection.

Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia.

OBJECTIVES To compare the efficacy and safety of finasteride 5 mg in older (65 years old or older) versus younger (45 to younger than 65 years old) men with benign prostatic hyperplasia (BPH). METHODS The Proscar Long-Term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men 45 to 78 years old with symptomatic BPH, enlarged prostates, and no evidence of prostate cancer. The endpoints included urinary symptoms, prostate volume, occurrence of acute urinary retention and/or BPH-related surgery, and safety. RESULTS In both age cohorts, finasteride treatment led to a 51% reduction (P <0.001) in the relative risk for acute urinary retention and/or BPH-related surgery, a significant (P <0.001) and durable improvement in symptom score, and a significant (P <0.001) and sustained reduction in prostate volume. Within each age cohort, no significant differences were found between the placebo and finasteride-treated patients in the incidence of cardiovascular adverse events. Significant differences were evident between the placebo and finasteride groups in the incidence of the typical, known, drug-related adverse events, but no specific differences were associated with age. No drug interactions of clinical importance were observed in the finasteride-treated patients. CONCLUSIONS The present analysis from PLESS demonstrates that in both older (65 years old or older) and younger men with symptomatic BPH and enlarged prostates, finasteride is highly effective in improving symptoms and reducing prostate volume in many men and in reducing the risk of acute urinary retention and BPH-related surgery. In addition, the safety profile of finasteride in both older and younger men is similar and no drug interactions of clinical importance were observed.

Intraoperative treatment planning for radioactive seed implant therapy for prostate cancer

We describe a procedure for intraoperative treatment planning for seed implantation. One hundred seven treatment plans have been analyzed at the Beth Israel Deaconess Medical Center and affiliated hospitals. The average time for the intraoperative procedure was 1. 74 hours. No significant difference in dose coverage to the prostate or normal tissues was evident.

RETROPERITONEAL MUCINOUS CYSTADENOMA PRESENTING AS A RENAL CYST

A 28-year-old woman presented with persistent left flank pain. History was significant for what was believed to be a left renal cyst. Previous percutaneous aspiration of the cyst had been followed by recurrence. Ultrasound revealed what appeared to be a large renal cyst. Computerized tomography showed a 9.0 x 10.0 x 19.0 cm. cyst in the left pericolic gutter. Magnetic resonance imaging demonstrated no evidence that the cyst was derived from any of the surrounding organs. Operation revealed a large retroperitoneal cyst, arising superiorly from the region of the lower pole of the left kidney, extending down into the left iliac fossa and medially extending behind the left hemicolon. The cyst was excised and was attached to the peritoneum in its most medial aspect. The cyst contained a cavity filled with a colorless, aqueous fluid within a tannish white, flat reticular fibrous lining. No solid regions or papillae were grossly identified. Pathological evaluation revealed a simple cyst, weighing 840 gm., with mucinous columnar epithelial lining and focal calcifications (see figure).

Magnetic resonance imaging in the evaluation of ureteropelvic junction obstructed kidney

Deaconess Medical Center and H&ard Medical ychool, Boston, Massachusetts Reprint requests: Mohammad R. Mostafavi, M.D., Beth Israel Deaconess Medical Center-, East Campus, UT-ology Department, 330 Brookline Avenue, Boston, MA 02215 Submitted: April 4, 1997, accepted: May 13, 1997 The patient presented with cholestatic jaundice during her pregnancy. An abdominal ultrasound demonstrated a severe right hydronephrosis. After delivery, an intravenous urogram (IVU) revealed a high-grade right ureteropelvic junction (UPJ) obstruction (Fig. 1). No calculi were observed on the scout film. MAG3 Lasix (Hoechst-Roussel Pharmaceuticals, Somerville, NJ) renal scan confirmed a high-grade right UPJ obstruction with 35% function of the right and 65% function of the left kidney. To determine whether there were any accessory vessels that would preclude her candidacy for endopyelotomy, magnetic resonance (MR) urography and angiography was performed. Anatomic MR urograms were obtained using heavily weighted imaging without contrast agent. The collecting system appeared bright (Fig. 2). Next, functional MR urography was performed by in-

Magnetic resonance urography and angiography in the evaluation of a horseshoe kidney with ureteropelvic junction obstruction

A 42-year-old man presented with gross hematuria, which prompted a urologic workup. Intravenous urogram (IVU) demonstrated a horseshoe kidney with fight-sided hydronephrosis. Furosemide renal scan confirmed an incomplete right ureteropelvic junction (UPJ) obstruction. Horseshoe kidney is the most common fusion anomaly, with an incidence of approximately i in 400 births and a predominance in men. It presents great variability in morphology, position, and vascular supply, making therapeutic approaches very challenging. Associated anomalies occur in at least one third of patients. These include UPJ obstruction, ureteral duplication, and reflux. To better evaluate the UPJ, a retrograde pyelogram was performed (Fig. 1). In this study, a gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) enhanced magnetic resonance urography (MRU) 1 was performed as an alternative to the invasive retrograde pyelogram (Fig. 2). A comparison of the IVU and the Gd-enhanced MRU is demonstrated in Figure 3. Lastly, a second bolus of Gd (30-mL Gd-DTPA) was administered to the patient for magnetic resonance angiography (MRA), which demonstrated multiple aberrant vascular supplies to the kidney (Fig. 4). This information is important to the surgeon in order that he may more accurately decide between the endourologic and open surgical approaches. A delayed MRU obtained after this second bolus provides superior imaging quality, allowing better delineation of the anatomy of the horseshoe kidney (Fig. 5). This case demonstrates the advantages of using MRU and MRA in the primary evaluation of renal obstruction. The technique offers superior imaging