Michael Marberger

Effect of Medical Management and Residual Fragments on Recurrent Stone Formation Following Shock Wave Lithotripsy

Minimal emphasis has been placed on the clinical sequelae of residual stone fragments following shock wave lithotripsy. Moreover, there are no studies investigating the role of medical therapy on the course of stone disease in patients with residual fragments. In this retrospective, nonrandomized review, we evaluated 80 patients who had undergone shock wave lithotripsy at various institutions in Texas and were referred to our mineral metabolism clinic for metabolic evaluation and medical management of the stone disease. Of the patients 31 were determined to be stone-free following lithotripsy, while 49 had residual stone fragments. All patients were contacted an average of 43.2 months (range 9 to 79) following shock wave lithotripsy and the radiographs were reviewed. Patients were placed into 4 groups after shock wave lithotripsy: stone-free or residual fragments on or off medical therapy. In the stone-free group (19 patients), medical treatment produced a significant decrease in stone formation from a median of 0.67 to 0.0 stones per patient per year (p < 0.001). In 36 patients with residual fragments stone formation before shock wave lithotripsy was higher than in the stone-free group but there was also a significant decrease in the stone formation rate from a median of 2.47 to 0.00 stones per patient per year while on medical therapy (p < 0.001). Of the 12 stone-free patients who did not remain on medical therapy there was a slight decrease in the stone formation rate from a mean of 0.83 to 0.40 stones per patient per year, although this decrease was not significant (p = 0.07). In 13 patients with residual fragments not on medical treatment there was only a minimal decrease in the stone formation rate from a median of 1.33 to 0.77 stones per patient per year (p = 0.06). We also assessed the significance of so-called clinically insignificant residual fragments (smaller than 5 mm.) following shock wave lithotripsy in 26 of the 36 patients with residual fragments. More than half of the 26 patients with clinically insignificant fragments in the group that did not continue on medical therapy demonstrated significant stone growth during followup, suggesting that these fragments were not insignificant. Moreover, only 16% of the patients with fragments smaller than 5 mm. demonstrated an increase in fragment size while on medical therapy, again suggesting that appropriate medical treatment can decrease the risk of recurrent stone formation or growth (p < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Gleason Scores from Prostate Biopsies Obtained with 18-Gauge Biopsy Needles Poorly Predict Gleason Scores of Radical Prostatectomy Specimens

Objectives: Prostate cancer is the most frequent cancer among men in the US. Histological grading is an important part of the diagnostic evaluation aside from clinical staging and serum PSA. The most commonly used grading system is the one described by Gleason. From a prognostic point of view, it is of considerable interest to know how accurate the needle biopsy Gleason score is in predicting the final score of the radical prostatectomy specimen. From an outcome research point of view, it is important to recognize that a stratification of patients by Gleason score may prove correct in patients undergoing radical prostatectomy, while in patients undergoing radiation or conservative management some of the well-differentiated cancers could actually be moderately and poorly differentiated, and some of the moderately differentiated might be poorly differentiated, thus favoring radical prostatectomy in a direct comparison of treatment efficacy. We aimed to determine (1) whether such undergrading exists, (2) what the magnitude of the bias is, and (3) whether it is common and similar in different institutions. Materials and Methods: We retrospectively reviewed the records of 415 patients who underwent radical prostatectomy in three Dallas area hospitals, excluding patients who received neoadjuvant therapy prior to surgery. Data of Gleason grades and score were collected from the needle biopsy and the radical prostatectomy specimen. Analysis was done using three categorization schemes for mild, moderate and poor differentiation for the three individual hospitals and the entire group. Results: The most common Gleason score by needle biopsy and prostatectomy was five. 37.2% of all patients had no change in score assignment, while 12.7% were ‘overgraded’ and 50.1% ‘undergraded’ by needle biopsy. The most common undergrading was by 1 or 2 score points. Only 23.7% of the category ‘well’ cancers remained so after surgery. Between 65.0 and 88.4% of the category ‘moderate’ cancers remained so after surgery. To determine the degree of agreement between needle biopsy and surgery category, kappa statistics were employed. The kappa value ranged from 0.148 to 0.328 for all categories and classification schemes indicating poor reproducibility. Serum prostate-specific antigen was not helpful in predicting Gleason score upgrading. Conclusions: Independent of the setting, about 50% of all Gleason score assignments made on needle biopsy specimen are revised in the direction of a worse score/category. It is important for clinicians to realize this phenomenon when consulting with patients regarding treatment choices if the grade is taken into consideration. For outcome research purposes, it is important to realize that this introduces a bias into direct comparisons between surgical and nonsurgical (radiation and watchful waiting) series favoring the outcomes of surgical series as the nonsurgical series suffer from a less favorable patient mix.

PROSPECTIVE RANDOMIZED COMPARISON OF HIGH ENERGY TRANSURETHRAL MICROWAVE THERMOTHERAPY VERSUS alpha-BLOCKER TREATMENT OF PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA

PURPOSEnWe compare directly the efficacy and safety of targeted high energy transurethral microwave thermotherapy with alpha-blocker treatment for benign prostatic hyperplasia (BPH).nnnMATERIALS AND METHODSnIn this randomized prospective study 52 patients with symptomatic BPH received terazosin and 51 underwent high energy transurethral microwave therapy with topical anesthesia. Patient evaluation included determination of International Prostate Symptom Score (I-PSS), peak flow rate and quality of life score before transurethral microwave therapy or terazosin and periodically up to 6 months thereafter.nnnRESULTSnAt 2-week followup the terazosin group transiently exhibited significantly greater improvement than the transurethral microwave therapy group in mean values of all 3 primary efficacy parameters of I-PSS, peak flow rate and quality of life score. At 12 weeks and 6 months this pattern was reversed, and the transurethral microwave therapy group achieved significantly greater improvement than the terazosin group in mean I-PSS, peak flow rate and quality of life score. By 6 months 78.4, 64.7 and 84.3% of the transurethral microwave therapy group demonstrated a 50% or greater improvement in I-PSS, peak flow rate and quality of life score, respectively, compared with 32.7, 9.6 and 40.4% of the terazosin group, respectively. Nine patients in the terazosin group and 1 in the transurethral microwave therapy group withdrew from study because of side effects or lack of treatment efficacy.nnnCONCLUSIONSnTerazosin afforded more rapid improvement in symptoms, voiding function and quality of life in BPH patients. High energy transurethral microwave therapy offered markedly superior clinical outcomes at 12 weeks to 6 months.