Ibrahim Cevik

Lack of effect of intrarectal lidocaine for pain control during transrectal prostate biopsy: a randomized prospective study.

INTRODUCTION AND OBJECTIVES Transrectal ultrasound guided biopsy is an essential part in the diagnosis of prostate cancer. Although this procedure is well tolerated by most patients, sometimes it can result in some uneasiness. In this randomised double-blind placebo controlled study, we evaluated the effectiveness of intrarectal lidocaine during TRUS guided biopsy. MATERIALS AND METHODS 100 consecutive eligible patients who had elevated total prostate specific antigen (tPSA) and/or abnormal digital rectal examination (DRE) were included into this study. Patients were randomised into two groups. Group I received 20 cc of 2% intrarectal lidocaine 20 minutes before transrectal ultrasound guided biopsy and Group II received same amount of serum physiologic. Pain was assessed using a 10 point modified visual analog scale. RESULTS Mean patient age was 65.5+/-2.5 and 64.5+/-11.5 years, mean tPSA was 12.3+/-3.6 and 11.3+/-1.7 ng/ml, mean biopsy duration was 6.8+/-2.5 and 6.6+/-2.2 minutes, mean pain score during transrectal ultrasound guided biopsy was 4.8+/-2.2 and 4.4+/-2.1 in Groups I and II, respectively. No statistically significant difference was observed with respect to age, tPSA, mean biopsy duration and pain score between these groups. There was only one patient who could not tolerate the procedure at all, and he was paradoxically in the lidocaine group. CONCLUSION The use of intrarectal lidocaine is not superior to placebo during transrectal prostate biopsy for pain control.

Is stent placement necessary after uncomplicated ureteroscopy for removal of impacted ureteral stones

BACKGROUND AND PURPOSE Ureteral stent placement after ureteroscopic lithotripsy has some advantages and disadvantages. In this randomized study, the necessity of ureteral stent placement after uncomplicated ureteroscopy for impacted ureteral stones was assessed. MATERIALS AND METHODS Between 2005 and 2007, 60 evaluable patients were equally randomized to groups with and without stents. Patients underwent ureteroscopic pneumatic lithotripsy for ureteral stones. The operation was completed with or without stent placement according to the randomization order. Excretory urography was performed 3 months after the procedure. All stents were cystoscopically removed at the third postoperative week. Sociodemographic and clinical variables (age, sex, stone location, stone size, operative time, hospital stay, narcotic and nonnarcotic analgesic use), and postoperative complications (fever, pain delaying discharge, emergency department visit, urinary retention, stent-related irritative symptoms) were evaluated. RESULTS Mean stone size was not significantly different in both groups. Mean operative time was significantly longer in the stent group: 30.5 +/- 9.6 vs 43.7 +/- 11.6 minutes. On the operation day and until postoperative day (POD) 5, narcotic (P = 0.004) and nonnarcotic analgesic (P = not significant) use was more frequent in the no-stent group. At POD 5 and later, although narcotic and nonnarcotic analgesic use were frequently necessary in the stent group, both were almost unnecessary in the no-stent patients. Stent-related irritative symptoms were overwhelmingly higher (10% vs 93%) in the stent group. Discharge was delayed (23% vs 10%) and unplanned emergency department visits (20% vs 10%) were exercised almost two times more commonly in the no-stent group. Stone-free rates were identical (n = 29/30; 97%) in both groups. CONCLUSION Routine placement of a ureteral stent is not mandatory in patients without complications after ureteroscopic lithotripsy for impacted ureteral stones. Stent placement can be argued and agreed with the patients preoperatively in the light of the data presented above.

Short-term effect of digital rectal examination on serum prostate-specific antigen levels. A prospective study.

OBJECTIVE Prostate-specific antigen (PSA) is widely used as a tumor marker in the early detection of prostate cancer. However, its value is limited by several factors such as not being specific for the cancer tissue, diurnal variations of the secretion, and changes in the serum levels observed following rectal manipulations. The effect of digital rectal examination (DRE) on serum PSA levels is still debatable. METHODS A prospective study is conducted by utilizing the IRMA count (monoclonal) PSA assay in order to determine the effect of DRE on PSA serum levels. A total of 50 men (median age 61, range 42-75 years) who presented to our outpatient clinic for the first time with lower urinary tract outflow obstruction symptoms were included in this study. Further evaluation revealed prostate cancer in 5 patients (10%) and benign prostate hyperplasia in the others. Blood samples were drawn for a PSA assay from all patients prior to and 30 min and 24 h following DRE (PSA 1-3). RESULTS The mean PSA values prior to and 30 min and 24 h following DRE were 4.09 +/- 0.67 range 0.2-19.47) ng/ml, 4.50 +/- 0.63 (0.15-17.75), and 4.28 +/- 0.68 (0.23-24.12) ng/ml, respectively. The median PSA levels for PSA 1, PSA 2, and PSA 3 were 2.49 +/- 4.74, 3.22 +/- 4.48, and 2.62 +/- 4.82 ng/ml, respectively. Although, there was a statistically significant increase in serum PSA levels 30 min after DRE, the clinical significance of this increase in PSA values with a mean difference of 0.4 ng/ml remains to be clarified. CONCLUSION Although the effect of DRE on PSA levels does not appear to be clinically significant, in order to prevent any confusion, it may be the best approach to perform DRE after obtaining serum for PSA analysis.

Impact of the Quadrivalent HPV Vaccine on Disease Recurrence in Men Exposed to HPV Infection: A Randomized Study

INTRODUCTION Human papillomavirus (HPV) is one of the most common sexually transmitted infections and is the cause of several different diseases in men and women. Although little is known about HPV infection in men, they are also in the risk group of HPV infection and play an important role in transmitting the virus to women. AIM To define the efficacy of the HPV vaccine through cross-immunization and its role in clearance of HPV infection, and to assess infection-associated factors in men. METHODS This prospective randomized clinical study enrolled 171 evaluable men with genital warts between June 2009 and October 2013. After the initial treatment intervention, 91 patients were randomly assigned to receive HPV vaccine in three doses. Eighty patients were in the control (unvaccinated) group. One hundred-eleven men were single and 60 men were married. Patients who had previous treatment for pre-existing warts and medical disorders that needed chronic treatment or immunosuppression were not included in the randomization. Also 29 men with follow-up less than 12 months and incomplete vaccination were not included. MAIN OUTCOME MEASURES The patients were assessed regarding age, condom use, marital status, number of visible genital warts, and smoking status. Post-treatment follow-up was monthly up to 12th month. RESULTS Mean age was 34 ± 7.6. One hundred fifteen patients were smokers. For the recurrence of warts, age, smoking, vaccination status were insignificant and marital status was significant in the univariable analysis; only marital status preserved significance (HR: 2.0 CI:1.29-3.12 P = 0.002) in the multivariable analysis including vaccination status, marital status, and smoking. CONCLUSION Among the investigated factors vaccination status was not but marital status significantly influenced wart recurrence. Married men had more recurrences in our population. Larger multicenter randomized clinical trials are lacking and seriously required to investigate the therapeutic effect of current quadrivalent HPV vaccine in genital warts.

Impact of prostate-specific antigen density in benign prostatic hyperplasia and prostate carcinoma. Preliminary results.

In an attempt to enhance the success of prostate-specific antigen (PSA) in the diagnosis and staging of prostate carcinoma (PCa) the concept of PSA density (PSAD) has been introduced by Benson et al. Likewise a study to investigate the role of PSAD in 53 patients with PCa and 47 patients with benign prostatic hyperplasia (BPH) has been done. PSADs seemed to increase directly proportional to the grade in PCa and differed significantly between patient groups with BPH and localized+metastatic PCa, BPH and localized PCa, and localized PCa and metastatic PCa. Although 0.6 level for PSAD seemed to be a rational cut-off level in our study, this issue needs to be studied in multiple centers involving an increased number of patients for resolution.

Prognostic influence of 5 alpha reductase ınhibitors in patients with localized prostate cancer under active surveillence

Objective The incidence of prostate adenocarcinoma (PCa) is increased with the use of prostate-specific antigen (PSA). In the current study, we aimed to investigate the impact of 5- alpha- reductase inhibitors (5-ARI) on pathological progression in patients followed by active surveillance (AS). Material and methods Records of 69 patients with localized prostate cancer under AS (PSA ≤15 ng/mL, PSAD ≤0.20, ≤cT2c, Gleason sum ≤3+3, the number of cancer positive cores ≤3) were evaluated retrospectively. Patients were followed-up with quarterly PSA testing and semiannual digital rectal examination during the first 2 years, and semiannual PSA testing thereafter. Repeat biopsies were done annually and whenever indicated by clinical findings. Pathological progression was defined as increasing Gleason grade, number of cancer-positive cores, and/or increasing percentage of cancer in any core. Results Patients using (29/69: 42%) and not using (40/69: 58%) 5-ARI were followed for a median of 39 (IQR: 23-45) and 23.5 (IQR: 17-37.5) months, respectively. Pathological progression was observed in 32% (22/69) of the patients at a median of 25 (IQR: 18-39) months. Pathological progression was observed in 34.5% (10/29) and 30% (12/40) of the patients using and not using 5-ARI, respectively (Log-rank p=0.4151). Definitive treatment was done in 31% (9/29) and 47.5% (19/40) of the patients using and not using 5-ARI, respectively. Patients who did not use 5-ARI received definitive treatment earlier than 5-ARI users (Log-rank p=0.0342). On multivariate analysis, more than 2 cancer-positive cores (HR: 11.62) and age (HR: 0.94) were independently associated with pathological progression (p<0.05), rather than 5-ARI use (p=0.148). Conclusion More than 2 cancer- positive cores at the initial biopsy was the strongest covariate associated with pathological progression; these patients should not be offered AS. There was no impact of 5-ARI use on pathological progression in AS.

MP16-19 IMPACT OF THE QUADRIVALENT HPV VACCINE FOR MEN WHO EXPOSED TO HPV INFECTION

INTRODUCTION AND OBJECTIVES: Human papillomavirus (HPV) is one of the most common sexually transmitted infections. In 2009, FDA recommended HPV vaccine for the prevention of external genital lesions caused by HPV 6, 11, 16, or 18. There are conflicting results regarding cross protection from naturally occurring HPV infection. According to recent studies HPV vaccination can induce neutralizing antibodies across HPV species. Our purpose was to define the importance of immunization and its role in clearance of HPV infection and to assess infection-associated factors in men. METHODS: This prospective randomized trial enrolled 200 men with genital warts (GW), between June, 2009 and October, 2013. GW were diagnosed solely with their clinical features and their reaction to the aceto-white. Pathologic examination was performed in suspicious cases. Initial treatment was local excision with electrocautery or electrocautery alone in all patients. After the initial intervention, 200 patients were randomly assigned to receive a HPV vaccine in three doses (0, 2, 6 mos). Hundred patients were in the control (unvaccinated) group. All men were circumcised and reported only female sexual partners. Thirtynine men were excluded due to pre-existing medical disorders that needed chronic treatment or caused immunosuppression, follow-up (F/ U) less than 12 months and incomplete vaccination. Finally, 171 consecutive patients were included in study. There were 91 men in the vaccinated group and 80 men in the control group. One hundred-eleven were single and 60 men were married. The patients were assessed regarding age, marital status (MS), number of GW, physical examination and smoking status. Post-treatment F/U was monthly up to 6 months and one more at the 12th mo. GW recurrences were analyzed with Cox proportional hazards model. RESULTS: Mean age was 34 7.6. One hundred-fifteen (67.25%) patients were smokers. For the recurrence of GW, age, smoking, vaccination status (VS) were insignificant and MS was significant (p<.001) in the univariable analysis; MS (Figure) preserved significance (HR:2.0 CI:1.29-3.12 p1⁄4.002) in the multivariable analysis (with VS, MS). CONCLUSIONS: Among the investigated factors not VS but MS significantly influenced wart recurrence. Interestingly, married men had more recurences in our population.