Klaus G. Fink

Improvement of specificity in PSA-based screening by using PSA-transition zone density and percent free PSA in addition to total PSA levels

The clinical value of prostate‐specific antigen (PSA) density in differentiating between prostate cancer and benign prostatic hyperplasia has been the subject of several studies. In this context the question has been raised about the diagnostic benefit of PSA transition‐zone density (PSA‐TZ density = total PSA/transition‐zone volume) in the detection of prostate cancer. In the following study the value of PSA‐TZ density alone and in combination with free PSA was investigated.

Usefulness of the ratio free/total prostatespecific antigen in addition to total PSA levels in prostate cancer screening

OBJECTIVES Two different studies were performed. The aim of the first study was to define whether the measurement of the ratio between free and total prostate-specific antigen (f/t PSA) in serum may enhance the ability of PSA-based screening for early detection of prostate cancer in men with elevated serum PSA levels. A second study was undertaken to investigate the value of f/t PSA ratio in serum to improve the specificity of prostate cancer screening in men with serum PSA levels between 2.5 and 10.0 ng/mL. METHODS In a retrospective study of 266 men with elevated PSA levels and proven biopsy results, f/t PSA levels were measured using deep frozen serum samples. In a second study we enrolled 158 men with elevated PSA levels according to age reference ranges apparent from our current PSA screening study with additional measurement of the f/t PSA ratio. All study volunteers with a free f/t PSA ratio cutoff point of < or = 22% underwent digital rectal examination, transrectal ultrasonography, and biopsy of the prostate. Free and total PSA levels were measured with the Delfia PSA dual label f/t PSA kit (Wallac Oy Turku, Finland). RESULTS 106 of 158 men with elevated total PSA values between 2.5 and 10.0 ng/mL (group 1) have been further evaluated and 37 prostate cancers were detected. Mean percentage of free PSA was 10% in men with cancer and 22% in men with benign prostatic hyperplasia. Using a f/t PSA ratio of < or = 22% as a biopsy criterion 30% of the negative biopsies could be eliminated while still detecting 98% carcinomas. CONCLUSIONS Measurement of f/t PSA reduces the number of unnecessary biopsies in PSA screening without missing many cancers.

Prostate cancer detection with two sets of ten-core compared with two sets of sextant biopsies

OBJECTIVES To compare the cancer detection of two consecutive sets of prostate biopsies using either the sextant or the 10-core technique. METHODS Ninety-one specimens after radical prostatectomy were used and consecutive sets of biopsies were performed ex vivo on each prostate after the operation. The sextant biopsies were taken paramedian and midlobular, three per side. For the 10-core biopsies, two cores per side from the lateral areas of the prostate were added. We developed a realistic simulation of a transrectal sonographic biopsy procedure. RESULTS In the first set of sextant biopsies, 55 prostate cancers (60.4%) were found; in the second set, 13 additional tumors were detected. Two consecutive sets of sextant biopsies thus found 68 tumors (74.7%). Using one 10-core biopsy led to cancer detection in 71 of the prostates (78%). A second 10-core biopsy revealed 11 additional tumors, for a cumulative cancer detection rate of 90.1%. We found that 9 (9.9%) of all the cancers were not diagnosed by two consecutive sets of this extended biopsy protocol. Eight of these cancers (88.9%) were clinically significant as determined by a tumor volume larger than 0.5 cm(3). CONCLUSIONS Although the 10-core protocol is far superior to the commonly used sextant protocol, a significant number of prostate cancers can still be found on a second similar set of prostate biopsies. Even after two consecutive sets of 10-core biopsies, approximately 10% of the prostate tumors remained undetected. Most of them were clinically significant.

Prostate carcinoma screening in the county of Tyrol, Austria†

This article summarizes the experience and results of different prostate carcinoma screening projects using total prostate specific antigen (PSA) as the initial test and different diagnostic tests to improve specificity.

Evaluation of transition zone and lateral sextant biopsies for prostate cancer detection after initial sextant biopsy

OBJECTIVES To assess the value of transition zone and lateral sextant biopsies for the detection of prostate cancer after a previous sextant biopsy was negative. METHODS A total of 74 prostates after radical prostatectomy were used to perform biopsies ex vivo. First, a sextant biopsy was taken, then two different rebiopsy techniques were performed. Rebiopsy technique A consisted of a laterally placed sextant biopsy and two cores per side of the transition zones only. Rebiopsy technique B included a standard sextant biopsy and two cores per side from the lateral areas of the prostate. The biopsies were taken using ultrasound guidance to sample the areas of interest precisely. RESULTS The initial sextant biopsy found 39 prostate cancers. Rebiopsy technique A found 12 cancers (34%). In this group, a laterally placed sextant biopsy found 12 cancers; transition zone biopsies revealed cancer in 5 cases, but no additional tumor was found. Rebiopsy technique B detected 23 prostate cancers (66%). Fourteen tumors were found after a second standard sextant biopsy, and nine additional tumors were found in the lateral areas. CONCLUSIONS Sextant biopsy has a low sensitivity of only 53%. A biopsy including the transition zones is not the ideal technique for detecting the remaining tumors. Therefore, transition zone biopsies should be reserved for patients with multiple previous negative biopsies of the peripheral zone. A subsequent sextant biopsy with additional cores from the lateral areas of the prostate is favorable if rebiopsy is necessary after a negative sextant biopsy.

One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies

To compare the efficiency of different transrectal ultrasonography (TRUS)‐guided prostate biopsy techniques for detecting prostate cancer.

Prostate Biopsy in Central Europe: Results of a Survey of Indication, Patient Preparation and Biopsy Technique

Objective: We surveyed urologists in Austria, Germany and Switzerland regarding their standard approach to prostate biopsy. Methods: Participants of Austrian and German urological meetings were asked to fill out a survey form; additionally, this was mailed to all Swiss urologists. Results: 304 surveys are available for analysis. 97% of participants perform a biopsy if digital rectal examination is abnormal. 63% use 4 ng/ml PSA (prostate-specific antigen) as cut-off. Age-related reference ranges are used by 54%, free PSA by 57%. 22% use PSA density, 55% PSA velocity. Overall 61% require a written consent, with 85, 86 and 25% in Austria, Germany and Switzerland. 96% of the urologists prescribe a quinolone antibiotic with a wide range regarding the start and end of drug therapy. 77% offer some kind of anaesthesia. Periprostatic injection of a local anaesthetic drug is used by 36%, lidocaine gel by 27%. 91% perform the biopsies transrectally under ultrasound guidance. Digitally guided biopsies are used by 11%. Only 3 participants perform perineal biopsies. The mean number of cores per biopsy session is 9.2, the maximum number of cores is 15.3 as a mean. Participants will stop performing any further biopsies if the patient already had a mean of 3.5 biopsy sessions. Conclusions: The majority of urologists in Central Europe prescribe a quinolone antibiotic and recommend some type of analgesia. The majority has abandoned the sextant technique and increases the number of cores in the case of rebiopsy. Biopsies are stopped after a mean of 3.5 sessions.

The use of Duloxetine in the treatment of male stress urinary incontinence

ZusammenfassungBelastungsinkontinenz kann Folge chirurgischer Eingriffen an der Prostata sein. Bis jetzt gibt es hierfür keine etablierte medikamentöse Therapie. Aktuell ist Duloxetin, ein Serotonin und Norepinephrin Wiederaufnahmehemmer zur Therapie der Belastungsinkontinenz der Frau zugelassen. Die vorliegende Studie beschreibt die Wirkung bei Männern mit Belastungsinkontinenz nach radikaler Prostatektomie oder transurethraler Elektroresektion. 56 Patienten wurden in unsere Analyse aufgenommen, 49 nach radikale Prostatektomie und 7 nach transurethrale Elektroresektion. Alle Patienten erhielten initial ein Beckenbodentraining. Bei ausbleibendem Erfolg verabreichten wir 2 × 40 mg Duloxetin. Unter Duloxetin reduzierte sich der Verbrauch an Inkontinenzvorlagen von 3,3 auf 1,5 pro Tag. 14 Patienten verwendeten keine und 18 nur mehr eine Vorlage pro Tag. Die meisten Patienten berichteten von milden Nebenwirkungen welche nach einigen Wochen vergingen. 13 bezeichneten ihre Nebenwirkungen als moderat und 9 als stark. Das Ergebnis dieser Anwendungsstudie zeigt, dass Duloxetin effektiv bei Belastungsinkontinenz nach Prostataoperationen verwendet werden kann, auch wenn ein gezieltes Beckenbodentraining keinen Erfolg brachte.SummaryStress urinary incontinence (SUI) is a known complication after prostate surgery. To date no pharmacologic treatment is available. Currently Duloxetine, a serotonin and norepinephrine reuptake inhibitor, is available for women with SUI. This study investigates the effect of Duloxetine on men with SUI after prostate surgery. 56 patients were included in our study. 49 after radical prostatectomy and 7 after TURP. All patients were initially treated with pelvic floor exercises. Thereafter 40 mg Duloxetine was administered twice daily. When taking Duloxetine, the average use of incontinence pads decreased from 3.3 to 1.5 per day. 14 patients needed no and 18 a single pad per day. Most patients reported mild and temporary side effects, 13 patients assessed them to be moderate and 9 being severe. The results of this off-label use show that Duloxetine is effective in men with SUI after prostate surgery even if standard pelvic floor exercises have failed.

Lidocaine suppositories for prostate biopsy

To evaluate, in a randomized prospective study, the efficiency of transrectal lidocaine suppositories to reduce pain during transrectal prostate biopsy, as suppositories allow longer for the agent to be effective.

Prostate Biopsy Outcome Using 29 mm Cutting Length

Objectives: The aim of the study was to compare the prostate biopsy outcome by using either standard or extended cutting length of the needles. Material and Methods: A total of 74 consecutive prostates from radical prostatectomy were used. Two sextant biopsies were performed ex vivo. We developed a precise simulation of a transrectal biopsy procedure using ultrasound for guiding the needle. In the first set of biopsies an 18-gauge tru cut needle with 19 mm cutting length, powered by a automatic biopsy gun was used. In the second set a single use gun with an 18-gauge end-cutting needle and 29 mm cutting length was used. Results: In the set of sextant biopsies using 19 mm cutting length 49 (66%) carcinomas were found. In the set of sextant biopsies using 29 mm cutting length 58 (78%) of the tumors were detected. 24 (32%) prostates showed tumor in the transition zones, but there was no transition-zone-only cancer in this study. Nevertheless taking longer cores led to an improvement in prostate cancer detection of 18%. Conclusions: In this ex vivo settingthe use of 29 mm cutting length for prostate biopsy led to an significant improvement in cancer detection. As we found the end-cutting needle not suitable for use in the patient, these results support the idea to develop a longer tru cut needle and corresponding gun for further clinical investigations.