Sandy S. Kim

THE PROCEDURE OF TRANSRECTAL ULTRASOUND GUIDED BIOPSY OF THE PROSTATE: A SURVEY OF PATIENT PREPARATION AND BIOPSY TECHNIQUE

PURPOSE We surveyed urologists in community and academic practice regarding their standard approach to patient preparation and their technique of transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS We mailed 110 surveys to community urologists in Florida and urological oncologists at academic centers across the United States. Responses were calculated per group. RESULTS Of the 88 respondents 34% were at academic centers and 66% were community urologists. Overall 79% of respondents prescribe an enema in preparation for biopsy, 81% administer an oral fluoroquinolone before biopsy, 50% give some type of analgesia, usually an oral agent, 63% obtain 8 or more cores per biopsy session, 36% biopsy the lateral and midline locations, and 83% do not use prostate specific antigen density to plan the biopsy strategy. CONCLUSIONS The majority of urologists who responded to our survey ask their patients to use an enema in preparation for a transrectal biopsy procedure, prescribe an oral antibiotic and administer some type of analgesia. Few urologists administer a periprostatic nerve block. The majority obtain at least 8 biopsies and only 17% perform sextant biopsy. Some of these practices are not consistent with the literature. This survey provides insight into the practice patterns of urologists in regard to one of the most commonly performed office procedures.

Sexual, psychological and dyadic qualities of the prostate cancer 'couple'.

To examine the levels of sexual, psychological and dyadic functioning of the prostate cancer ‘couple’ (as studies have shown that spouses/partners play an integral role in the patients adjustment to prostate cancer treatment), to encourage the creation of innovative psychosexual interventions to be used in the outpatient setting, and to offer insights into a novel area of prostate cancer research.

Prostate Specific Antigen Recurrence Rates are Low After Radical Retropubic Prostatectomy and Positive Margins

PURPOSE Treatment in patients with a positive surgical margin after radical retropubic prostatectomy is controversial. Options are observation, radiation therapy and early hormone therapy. Making the appropriate choice should be based on an understanding of the risk of recurrence without treatment. MATERIALS AND METHODS We reviewed the records of 1,383 patients after radical retropubic prostatectomy was performed by a single surgeon. All specimens were analyzed by a single pathologist. Of the patients 936 met criteria for analysis. RESULTS Mean followup in these 936 patients was 45.8 months (minimum 12). The overall PSA biochemical recurrence rate was 11.5% (108 of 936 cases). Of the 936 patients 350 (37%) had tumor at an inked margin. These patients had a recurrence rate of 19% (67 of 350), while patients with negative margins had a recurrence rate of 7% (41 of 586). This difference was statistically significant (p <0.01). Multivariate HR analysis revealed that significant risk factors for recurrence in the 936 patients were PSA greater than 20 ng/ml, clinical stage T2 or greater, Gleason 7 or greater, seminal vesicle involvement, extraprostatic extension, a visual estimate of prostate cancer volume of greater than 9.1% and positive surgical margins. Statistically significant risk factors for recurrence in patients with a positive margin on multivariate HR analysis were PSA greater than 20 ng/ml, Gleason score 7 or greater and seminal vesicle involvement. CONCLUSIONS Although the positive margin rate in this series was 37%, the recurrence rate in these patients was only 19%. It is important to consider other factors, such as PSA, Gleason score, seminal vesicle involvement and extraprostatic extension, when making treatment decisions.

Radionuclide bone scintigraphy in patients with biochemical recurrence after radical prostatectomy: when is it indicated?

To evaluate the use of radionuclide bone scintigraphy following biochemical recurrence after radical retropubic prostatectomy (RRP) for localized prostate cancer.

Urethral recurrence after cystoprostatectomy: Implications for urinary diversion and monitoring

OBJECTIVES To review our cystoprostatectomy (CP) database to determine the urethral recurrence rate. Urethral recurrence after CP has been reported to occur in up to 10% of patients. Recent data have suggested a much lower incidence. This has important implications when considering the type of urinary diversion and postoperative monitoring. METHODS We retrospectively analyzed our single-surgeon, consecutive CP series and determined the urethral recurrence rate and prognostic factors for recurrence. Urethrectomy was performed at CP if the prostatic apical margin was positive for carcinoma. All patients were followed up quarterly for 2 years and then semiannually. Urethral wash cytology was obtained if the patient had an ileal conduit. Cytology and cystoscopy were performed if they had an orthotopic neobladder. RESULTS A total of 226 men had undergone radical CP. The mean age for all patients was 69 years. Eight (3.5%) had undergone urethrectomy at CP. The mean follow-up was 42 months for the remaining 218 patients, of whom 108 had an orthotopic neobladder and 110 had supravesical diversion. Of the 218 patients, 8 (3.7%) developed urethral recurrence, 7 (6.4%) in the 110 who had undergone supravesical diversion and 1 in the 108 (0.9%) who had an orthotopic neobladder. Seven patients underwent urethrectomy for the recurrence and had no evidence of disease at last follow-up. One patient died of metastatic transitional cell carcinoma at 61 months. CONCLUSIONS In our series, the risk of urethral recurrence after radical CP was low. The risk was substantially lower for patients who had an orthotopic neobladder. Our results show that urethrectomy at CP is rarely necessary because the proximal urethral margin is usually free of cancer. An orthotopic neobladder can therefore be safely considered in most patients. Delayed urethrectomy can be safely performed in those few patients with isolated urethral recurrence without compromising their survival.

Outcome after radical prostatectomy with a pretreatment prostate biopsy Gleason score of ≥8

The use of radical prostatectomy to treat patients with high‐grade prostate cancer is the subject of much discussion, and the authors from Miami present their considerable experience in this field. They show that patients with a pre‐treatment biopsy of Gleason score of ≥8 may benefit from radical prostatectomy, assuming a clinical stage of T1–T2, and particularly if their PSA level is <20 ng/mL.

Biochemical And Pathological Predictors Of The Recurrence Of Prostatic Adenocarcinoma With Seminal Vesicle Invasion

PURPOSE We assessed biochemical and pathological factors as predictors of recurrence in men with seminal vesicle invasion. MATERIALS AND METHODS A consecutive series of 812 men who underwent radical retropubic prostatectomy between 1992 and 2000 included 106 (13%) with seminal vesicle invasion. Disease recurrence was defined as prostate specific antigen (PSA) 0.4 ng./ml. or greater. Patients with less than 12 months of followup, salvage radical retropubic prostatectomy, lymph node metastases and adjuvant therapy were excluded from study. Data on the remaining 66 cases were analyzed using the chi-square test, bivariate logistic regression, Kaplan-Meier analyses and Cox proportional regression. Variables included demographics, recurrence, time from surgery to recurrence, positive margins, capsular invasion, extracapsular extension, Gleason score (2 to 6, 7 and 8 to 10), and dichotomized values of preoperative PSA (10 or less versus 10 ng./ml.) and tumor volume (20% or less versus greater than 20%). RESULTS Mean patient age was 62 years (range 48 to 74). At an average followup of 47.7 months (range 13 to 109) 53% of the patients were free of biochemical recurrence. Mean time to recurrence was 18.6 months (range 1.7 to 51.6). Univariate analyses revealed a statistical significant increased risk of recurrence in patients with PSA greater than 10 ng./ml. (p <0.0001), capsular invasion (p = 0.01) and age (p = 0.036). When adjusting for potential covariates, Cox proportional regression analysis indicated that higher PSA (hazard ratio 7.33, 95% CI 2.57 to 20.95), larger tumor volume (hazard ratio 5.64, 95% CI 1.97 to 16.19) and higher age (hazard ratio 1.13, 95% CI 1.04 to 1.22) were significantly associated with shorter time to recurrence. CONCLUSIONS PSA greater than 10 ng./ml., tumor volume greater than 20% and age are significant predictors of recurrence after radical retropubic prostatectomy in patients with prostate cancer and seminal vesicle invasion. Hopefully future randomized trials may show a survival benefit of adjuvant therapy in patients at high risk.

Upper tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: incidence and risk factors.

The considerable experience of the University of Miami in treating TCC is reviewed in the first article in this section. The authors found that the incidence of upper tract tumour after radical cystectomy for TCC is low, but that patients with prostatic urethral involvement at cystectomy have a greater risk of developing upper tract tumours.

Venous thromboembolism in radical prostatectomy: is heparinoid prophylaxis warranted?

To review the incidence of venous thromboembolism (VTE) after radical retropubic prostatectomy (RRP) and evaluate the need for heparinoid prophylaxis as opposed to mechanical compression devices after RRP.

Limitations of noncontrast CT for measuring ureteral stones.

BACKGROUND AND PURPOSE Patients with renal colic are frequently evaluated in the emergency room with a helical noncontrast CT scan (NCCT) as the primary imaging modality. Treatment decisions are often based on the size of the ureteral stone(s). We wished to assess the accuracy of NCCT in estimating ureteral stone size compared with plain abdominal (KUB) films. PATIENTS AND METHODS Forty-eight patients were identified who had ureteral stones seen on NCCT and KUB films performed on the same day. The number of consecutive images on which a ureteral stone was visible on NCCT was multiplied by the reconstruction interval of 5 mm to create a size estimate, which was compared with the measurements of the same stone seen on the KUB film. RESULTS The NCCT overestimated stone size by approximately 30% to 50% compared with KUB. CONCLUSION Counting the number of consecutive NCCT images depicting a ureteral stone is not an accurate method of stone measurement when a reconstruction interval of 5 mm is used. Urologists should consider stone measurement techniques carefully and understand the limitations of imaging studies when evaluating patients with symptomatic ureteral stones.