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Objectives: To examine the value of post-operative serum prostate-specific antigen (PSA), PSA density, incremental change in serial serum PSA (PSA slope) and transrectal ultrasound (TRUS) in the assessment of residual malignancy after the diagnosis of clinically unsuspected prostatic adenocarcinoma at transurethral resection of the prostate (TURP)., Patients and Methods: Forty-eight untreated patients with incidental carcinoma of the prostate, demonstrated at TURP for a clinically benign gland, were evaluated post-operatively with serum PSA and TRUS with multiple systematic prostatic biopsies. Prostatic volume was determined from TRUS measurements and PSA density was defined as serum PSA divided by gland volume. Those patients who did not undergo further treatment were monitored with serial PSA levels, and PSA slope was calculated as the overall annual percentage increase in serum PSA., Results: Among 36 patients staged T1A (A1), 11 (31%) had histologically proven residual carcinoma, and five of the 12 patients (42%) with T1B (A2) disease had no residual disease on biopsy. Serum PSA levels following TURP were greater in those patients with residual disease than those without (P = 0.001), but at a cut-off of 4.0 ng/mL--providing a sensitivity of 89%--the specificity of PSA alone was 57%. PSA density had an 83% sensitivity and a 67% specificity with a cut-off of 0.15 ng/mL/cm3. TRUS had a sensitivity of 63% and a specificity of 52%. An incremental rise in PSA exceeding 20% per year in untreated patients gave a sensitivity of 90% and specificity of 79% for biopsy proven residual malignancy., Conclusion: This study demonstrates the inaccuracy of staging incidental prostatic malignancy by TURP. Although the performance of PSA density is better than that of PSA alone, the reliability of both are limited by the lack of specificity, and TRUS imaging lacks both sensitivity and specificity. The PSA slope has sufficient sensitivity and specificity to distinguish reliably most patients with biopsy proven residual malignancy. Although ultrasound-guided systematic biopsies provide a means for confirming residual malignancy, they may not be indicated in all patients with incidental carcinoma: for such patients, PSA progression may provide a rational basis for subsequent treatment.

Objective: To examine the feasibility and acceptability of screening for cancer of the prostate by digital rectal examination (DRE), prostate specific antigen (PSA) determination and subsequent transrectal ultrasound (TRUS) in selected patients in a single general practice in Hertfordshire., Subjects and Methods: A total of 568 of 856 men aged 55 to 70 accepted an invitation for a health check which included screening for prostate cancer. Of these, 80 individuals with either a raised PSA level or an abnormal DRE underwent TRUS. In 29 individuals biopsies were taken, 11 of which confirmed the presence of adenocarcinoma of the prostate giving an overall detected prevalence of 2%. Of the 11 tumours identified by screening, two were T1M0, four were T2M0, two were T3M0 and three were T3M1., Results: To assess the acceptability of the screening exercise a postal questionnaire was sent to all 568 participants: 83% replied and 69% reported no concern. Of the 67 individuals who had undergone TRUS, 69% reported discomfort. A total of 448 (95%) of respondents declared that they would be prepared to undergo the screening exercise again., Conclusion: Screening for prostate cancer would seem to be technically feasible and generally acceptable. However, there is a considerable false positive rate in the PSA range 4 ng/ml to 10 ng/ml, particularly among men with clinical evidence of benign prostatic hyperplasia. To establish the true benefit of screening a large-scale prospective controlled study will be necessary.

A prospective study of the complications of transperineal prostate biopsy was undertaken in 171 patients; 150 (88%) returned a questionnaire 1 week after biopsy. The incidence of serious complications was low, with 1 patient requiring admission for presumed septicaemia and another developing acute retention of urine. Many patients had minor complications, with 42% having haematuria, 13% haemospermia and 31% pain. Only 18% needed analgesia following biopsy. Since transperineal prostate biopsy has such a low incidence of infective complications, we suggest that it should be considered in frail or elderly patients in whom septicaemia may be especially hazardous.

A group of 69 men with bladder outflow obstruction due to benign prostatic hyperplasia (BPH) were treated in a double-blind, placebo-controlled study with finasteride (Proscar, MK-906), a 5-alpha reductase inhibitor, 5 mg or 10 mg/day or placebo for 3 months; subsequently, 20 patients received finasteride 5 mg/day for a further 9 months in an open extension study. In treated patients dihydrotestosterone declined by over 60%, remaining unchanged with placebo. Symptom scores fell significantly in all 3 groups. Mean maximum flow rates fell slightly in placebo-treated patients but improved by 1.5 ml/s in the 10 mg group and by 3.3 ml/s in the 5 mg group. After 1 year's treatment, the reduction in symptom score and increase in flow rate were well maintained; the mean prostate volume was reduced by 14% and prostatic specific antigen declined by 28%. It was concluded that finasteride shows some efficacy in the treatment of BPH, with minimal toxicity, but 12 months of therapy or longer may be necessary to achieve maximal effect.

Ultrasound was used to assess venous extension in 28 patients with renal carcinoma, with particular reference to involvement of the inferior vena cava. The findings were correlated with surgical findings in all except two patients who had gross caval involvement and metastatic disease and in whom surgery was considered inappropriate. In 10 of the 28 patients (36%), a diagnostic ultrasound examination of the cava from the renal veins to the diaphragm was obtained. In four of these, ultrasound showed tumour involvement of the vena cava. In 12 cases (43%) only the intrahepatic part of the cava was seen, but the examination nonetheless excluded tumour involvement of the upper cava. Visualisation of the vena cava was impossible in six cases (21%), usually because of bowel gas or obesity; CT scanning provided valuable additional information in two of these cases. Inferior vena cavography confirmed the findings of the less invasive imaging procedures in 10 patients and was falsely positive once. Cavography is now seldom necessary in the assessment of renal carcinoma.

We report an analysis of 68 of 1112 couples who attended an infertility clinic where the man had past or present evidence of testis maldescent. The age at orchiopexy for these 68 men was later than would be expected, taking into account surgical practice in Scotland for the relevant time period and this supports the view that late orchiopexy is a risk factor for subsequent infertility. There was no evidence that antisperm antibodies are responsible for the damage to spermatogenesis in unilateral cases; however, measurement of the serum hormones showed elevations of LH and FSH which cannot be entirely explained as secondary to the damaged spermatogenesis. There was weak but nevertheless significant evidence that testis maldescent may be a poor prognostic factor as far as subsequent fertility is concerned and that this is independent of the length of time the couple have been trying and the man's motile sperm density. In two men there was intra-abdominal undescent and both were found to have testis tumours; we would re-emphasise that abdominal exploration is mandatory in such cases.