David L. McCullough

Nephrolithiasis Clinical Guidelines Panel Summary Report on the Management of Staghorn Calculi

The American Urological Association Nephrolithiasis Clinical Guidelines Panel recommendations for managing struvite staghorn calculi are based on a comprehensive review of the treatment literature and meta-analysis of outcome data from the 110 pertinent articles containing viable, unduplicated data. The panel concluded that the 3 most significant outcome probabilities are those of being stone-free, undergoing secondary unplanned procedures and having associated complications. Panel guideline recommendations for most standard patients are that neither shock wave lithotripsy monotherapy nor open surgery should be a first-line treatment choice but that a combination of percutaneous stone removal and shock wave lithotripsy should be used.

Transurethral ultrasound-guided laser-induced prostatectomy: National Human Cooperative study results.

Between November 1990 and March 1992, 150 patients at 10 United States institutions were treated with transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for the relief of bladder outlet obstruction secondary to benign prostatic hypertrophy. The TULIP system incorporates ultrasound visualization with a 90-degree angle, side-firing laser to effect coagulation necrosis of prostate tissue. The overall preoperative prostate volume in this TULIP study was 40 cc and all types of prostatic enlargement, including median lobe obstruction, were treated. There were no intraoperative complications, with no hemorrhage or post-transurethral resection syndrome, and no blood transfusions were required. Hospital stay averaged 1.7 days and 83% of the patients went home after a 1-night stay. We evaluated 63 patients at 6 months after the TULIP procedure. Mean symptom scores decreased from 18.8 to 6.1, for a 68% improvement. The mean peak flow increased from 6.7 ml. per second preoperatively to 11.9 ml. per second, for a 78% improvement. Overall, 87% of the patients exhibited at least 50% improvement in either the symptom score or peak flow parameter, while 49% of the patients demonstrated at least a 50% improvement in both parameters.

Editorial: Lessons learned from prostate biopsies.

to show that patients with PSA greater than or equal to 20 ng./ml. (especially those with an abnormal digital rectal examination) are quite likely to have prostate cancer if confounding factors are excluded, such as prostatitis or recent catheterization. If initial biopsies are negative subsequent biopsy is greater than 50% likely to reveal cancer. Although biopsy of patients with PSA greater than 20 ng./ml. is recommended, elderly, high risk patients who may also have an abnormal digital rectal examination are at risk for cancer. If indicated, little would seem to be lost (other than dollars) by omitting biopsy and putting such patients on a therapeutic trial of reversible androgen ablation. This article provides medicolegal support and data for omitting biopsy in such high risk patients after obtaining suitable informed consent from the patient or family. Kestin et al (page 1994) provide data regarding the predictive benefits of documenting the percentage of positive biopsy cores in patients treated with radiotherapy for prostate cancer. There are a myriad of prognostic factors one can study in regard to prostate cancer treatment outcomes. This report examines these factors and makes the case for the percent of positive biopsy cores as being useful as a predictor of biochemical and chemical failure. This article has an extreme amount of technical data and statistical analyses relative to a large number of factors which might affect prognosis. Patients with less than 33% positive cores had a 5-year biochemical failure rate of 17% and a clinical failure rate of 7%. Those with greater than 67% positive cores had 5-year clinical failure rates of 25% and 5-year biochemical failure rate of 43%. It is easy for pathologists to tell us the percent of positive cores. Some other pathological techniques such as the percentage of the total biopsy specimen involved with cancer (total length of adenocarcinoma total length of the biopsy cores 100) are much more labor intensive. Interestingly, the percent of positive cores seemed to be more reliable than the clinical T stage in predicting clinical and biochemical failures in multivariate and univariate analyses. For those interested in the technique of and the results obtained by studying prostate biopsy specimens, these 3 articles add useful data to the field. There appears to be an endless supply of helpful information one can derive from prostate biopsy.