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Introduction: Prostate cancer is the leading malignancy in men today and an increase in detected localized prostate cancers is expected in the years to come. Even though radical prostatectomy is an effective treatment, it is associated with a considerable morbidity in some cases and efforts are made to provide minimally invasive alternative treatment options with equal efficacy but fewer side effects., Methods: Cryosurgical ablation of the prostate (CSAP), brachytherapy, high-intensity focused ultrasound (HIFU) and radiofrequency interstitial tumor ablation (RITA) were evaluated after a literature review from a Medline Search (1966-1998). Furthermore, personal experience and latest data from the authors were taken into account., Results: All alternative treatments nowadays make use of sophisticated technology, including the latest ultrasound devices for exact planning and monitoring of treatment, leading to increased safety compared to treatments in the 1960s and 1970s. Five-year results of CSAP show a PSA <1 ng/ml in 60% of cases whereas brachytherapy is able to achieve PSA <1 ng/ml in 80% of cases in a selected group. Recent outcome data come close to results of radical prostatectomy series. HIFU and RITA are promising new technologies that proved to be able to induce extensive necrosis, but the follow-up is too short to determine their definite places in the treatment of prostate cancer., Conclusion: Two alternative treatment options for localized prostate carcinoma, CSAP and brachytherapy, have been studied with a sufficient number of patients and an adequate follow-up. The overall results of brachytherapy are favorable when compared to CSAP and are in the same range as the outcome after radical prostatectomy. HIFU and RITA are relatively new techniques based on sophisticated technology that are very promising at present, but a longer follow-up is mandatory.

The objective of this study was to assess the intra- and inter-investigator variation in the analysis of pressure-flow studies that were performed in men with lower urinary tract symptoms. Two hospitals were involved in this study. In each hospital 100 PFS were selected. Photocopies of printouts of all PFS were analyzed manually by six experienced investigators, including determination of P(detQmax) and Q(max). Afterward, all 200 PFS were analyzed again in a different order. For each P(detQmax) and accompanying Q(max) the AG-number was calculated. With these AG numbers, the intra-investigator SD, the inter-investigator SD and the intra- and inter-investigator SD combined were calculated. The intra- and inter-investigator SD combined was 10.7. This implies that if one investigator analyzes a PFS once and determines an AG number of 40, another investigator may determine an AG number between 40 +/- 2. 77*10.7 = 10-70, using a 95% confidence interval. The inter-investigator SD was 10.0 and the intra-investigator SD was 3.7. The reproducibility of the manual analysis of urodynamic studies is moderate owing to a considerable intra- and inter- investigator variation. This is mostly caused by the substantial intra-investigator variation.

Purpose: To evaluate the performance of a backpropagation artificial neural network (ANN) in the diagnosis of men with lower urinary tract symptoms (LUTS) and to compare its performance to that of a traditional linear regression model., Materials and Methods: 1903 LUTS patients referred to the University Hospital Nijmegen between 1992 and 1998 received routine investigation, consisting of transrectal ultrasonography of the prostate, serum PSA measurement, assessment of symptoms and quality of life by the International Prostate Symptom Score (IPSS), urinary flowmetry with determination of maximum flow rate (Qmax), voided volume and post-void residual urine and full pressure flow studies (PFS). Using a three-layered backpropagation ANN with three hidden nodes, the outcome of PFS, quantified by the Abrams-Griffiths number (AG-number), was estimated based on all available non-invasive diagnostic test results plus patient age. The performance of the network was quantified using sensitivity, specificity and the area under the ROC-curve (AUC). The results of the neural network approach were compared to those of a linear regression analysis., Results: Prostate volume, Qmax, voided volume and post void residual urine showed substantial predictive value concerning the outcome of PFS. Patient age, PSA-level, IPSS and Quality of life did not add to that prediction. Using a cut-off value in predicted and true AG-numbers of 40 cm. H2O, the neural network approach yielded sensitivity and specificity of 71% and 69%, respectively. The AUC of the network was 0.75 (standard error = 0.01). A linear regression model produced identical results., Conclusions: This study shows that at an individual level, the outcome of PFS cannot be predicted accurately by the available non-invasive tests. The use of ANNs, which are better able than traditional regression models to identify non-linear relations and complex interactions between variables, did not improve the prediction of BOO. Thus, if precise urodynamic information is considered important in the diagnosis of men with LUTS, PFS must be carried out. Both neural networks and regression analysis appear promising to identify patients who should undergo PFS, and those in whom PFS can safely be omitted. Furthermore, the ability of ANNs and regression models to predict treatment result should be evaluated.

The objective of this study was to assess the short-term test-retest variability of pressure-flow studies (PFS) in men with lower urinary tract symptoms (LUTS). By choosing a short interval between two consecutive PFS, but notably not performing two tests within a single session, both tests represent the same routine testing procedure. Eighty-nine patients with LUTS suggestive of bladder outlet obstruction or detrusor underactivity, who received PFS, were asked to undergo a second urodynamic evaluation within 4 weeks after the initial test. At both visits, specialized physicians performed the PFS. Obstruction was quantified using the Abrams-Griffiths number (AG number). Each patient was classified as obstructed, unobstructed, or equivocally obstructed according to the International Continence Society nomogram. As expected, no systematic difference was observed in AG number between the first and the second visit at the group level. There was, however, considerable variation at the individual level. The average within-patient standard deviation was 14 cm H(2)O. This finding shows that if a patient's AG number is 30 at the first visit, his true AG number can be any value between 30 +/- 1.96 * 14 = 3 to 57, owing to random variability alone. The average within-patient standard deviation did not differ significantly between sub-groups of obstruction and other variables such as patient age, symptom score, prostate volume, or residual volume. The variability appeared to increase slightly with an increased interval between visits. Of all patients, 39% changed at least one category of obstruction at the second visit and 3% changed from definitely obstructed to definitely unobstructed or vice versa. We conclude that PFS cannot stand the test of serving as a gold standard to identify bladder outlet obstruction in patients with LUTS.

We present a critical review of the recent literature and discuss the development and prospective view of the evaluations of transrectal ultrasound with regard to prostate malignancy. We illustrate this with personal experiences. Material and Methods: Based on a critical evaluation of clinical data we address the apparent shortcoming of greyscale transrectal ultrasonography in the assessment of prostate cancer. New developments and future possibilities are also discussed. Evaluation of the value of greyscale transrectal ultrasonography in the diagnosis of prostate cancer indicates a limited role, because of the non-uniform appearance of prostate cancer on the ultrasound images. Ameliorating of transrectal ultrasound, like the use of contrast ultrasonography, could improve the detection of prostate cancer. Although the use of greyscale transrectal ultrasonography lacks sensitivity and specificity for the diagnosis of prostate cancer, its use in volume measurement of the prostate and biopsy guidance is unquestionable. The first results of the application of contrast ultrasonography are promising, both in detection of prostate cancer as in treatment follow up. Other developments like improvement of transducer and computer technology could make the use of ultrasound more versatile. However, future research will indicate whether all these improvements will lead to clinical applications.

The purpose of the present study was to evaluate the long-term results of lower-energy transurethral microwave thermotherapy (TUMT) and to determine predictors for a favorable treatment outcome in an international multicenter study. A total of 1092 patients treated between April 1990 and September 1993 in 6 different centers in different countries were evaluated. All patients were treated in a nonblinded, noncontrolled fashion with the Prostatron thermotherapy device using the lower-energy treatment protocol Prostasoft 2.0. Collected data included voiding parameters, Madsen symptom scores, retreatments, types of retreatment, and dates of retreatment. Instrumental retreatment served as the end point for further evaluation. The average age of our patients was 67 years. At baseline the average uroflow rate was 8.7 ml/s. After treatment the improvement in uroflow was 2-3 ml/s. This was maintained for up to 5 years after treatment for the patients remaining in follow-up. The overall improvement in the Madsen symptom score was 5-6 points for these patients. There was no significant difference between the different centers. During follow-up, however, the number of patients remaining in follow-up decreased rapidly. The absolute instrumental retreatment rate appeared to be 26%; however, when patients no longer in follow-up were taken into account, the calculated retreatment rate was 39.6% (Kaplan-Meier survival analysis). Patients undergoing retreatment were younger at baseline and had a higher Madsen score, a bigger prostate, and a greater postvoid residual. No major complication was seen. Lower-energy TUMT gives a sustained objective and subjective improvement in patients with moderate symptoms and a low-grade bladder outflow obstruction. Patients with bigger prostates, severe symptoms, low rates of maximal uroflow, and large residuals are prone to have a higher degree of prostatic obstruction and are not the ideal candidates for this treatment. The absolute instrumental retreatment rate after 5 years was 26%. Moreover, no significant international difference in treatment outcome was found.

Objective: To determine the overall tolerability of urodynamic studies used in the assessment of men with lower urinary tract symptoms (LUTS), by assessing the objective and subjective morbidity experienced during and after urodynamic studies, and to assess the voiding complaints caused by the combination of urodynamic studies with flexible cysto-urethroscopy., Patients and Methods: A total of 103 men with LUTS, who underwent a urodynamic study combined with flexible cysto-urethroscopy, completed a questionnaire designed to assess objective and subjective symptoms and degree of bother, with emphasis on the urodynamic study. In addition, a urine specimen was analysed and cultured. In all, 78 patients who underwent a second urodynamic study completed the questionnaire twice., Results: The results of the first questionnaire showed that more than half of the patients experienced some urge after the urodynamic study and cysto-urethroscopy (56%); 35% of the patients experienced little and 19% experienced severe voiding discomfort after the combined investigations, compared with 24% and 5%, respectively, after a urodynamic study alone. Three patients (3%) had a symptomatic urinary tract infection. Haematuria, increased voiding frequency and increased nocturia occurred occasionally. Most of the patients found the urodynamic study less bothersome than they had expected (64%) and only 9% found it worse than expected. The overall degree of discomfort, experienced during and after the urodynamic study combined with cysto-urethroscopy, was low, and after a second urodynamic study was even lower., Conclusion: In contrast with earlier results, this clinic-based urodynamic investigation was associated with a low proportion of urinary tract infection, and low objective and subjective morbidity. The combination of a urodynamic study with a flexible cysto-urethroscopy does not cause significant additional voiding complaints. Most patients find urodynamic studies tolerable and not very bothersome.

Objectives: High-intensity focused ultrasound (HIFU) consists of focused ultrasound waves emitted from a transducer that are capable of inducing tissue damage. The histologic effects and clinical outcome of the HIFU treatment were studied in two different groups of men with prostate carcinoma., Methods: The HIFU treatment was performed under regional or general anesthesia with the Ablatherm device. In one group, HIFU was performed 7 to 12 days before radical prostatectomy, and meticulous histopathologic examination of the radical prostatectomy specimens was performed. The second group consisted of patients with localized prostate carcinoma for whom radical prostatectomy was not an option and who received HIFU treatment alone., Results: In 14 patients treated with HIFU before radical prostatectomy, complete necrosis was seen in the treated region in all cases. On the dorsal border, however, incomplete destruction of tissue was noted, and in 4 cases a small vital tumor focus was seen. In the second group, of those patients in whom the entire prostate was treated, a negative biopsy result and a prostate-specific antigen (PSA) level less than 4 ng/mL was obtained in 60% and a PSA nadir less than 0.5 ng/mL in 55% of patients., Conclusions: HIFU treatment results in the two groups clearly demonstrate the potential of this modality in the treatment of localized prostate carcinoma. This study showed that extensive coagulative necrosis can be obtained in the treated areas; however, exact targeting is crucial and a prerequisite for extended clinical application of HIFU.

Objectives: To determine the feasibility of contrast-enhanced three-dimensional (3D) imaging of the prostatic vasculature using power Doppler imaging and to analyze whether semiquantitative judgments of 3D images with respect to symmetry and distribution of vascular structures correlated with biopsy outcome., Methods: 3D power Doppler images were obtained before and after intravenous administration of 2.5 g Levovist. Subsequently, random and/or directed transrectal ultrasound (TRUS)-guided biopsies were performed. Vascular images were analyzed by two experts. Prostate vasculature was judged with respect to symmetry and vessel distribution using a (scale) grading system., Results: Eighteen patients with a suspicion of prostate cancer either because of an elevated prostate-specific antigen (greater than 4.0 ng/mL; Tandem-R-assay) or an abnormal digital rectal examination were included in the study. Prostate cancer was detected in 13 patients. Vascular anatomy was judged abnormal in unenhanced images in 6 cases, of which 5 proved malignant. Enhanced images were considered suspicious for malignancy in 12 cases, including 1 benign and 11 malignant biopsy results. Sensitivity of enhanced images was 85% (specificity 80%) compared with 38% for unenhanced images (specificity 80%) and 77% for conventional gray-scale TRUS (specificity 60%). Of 6 patients who showed no B-mode abnormalities, vascular patterns were judged abnormal in 4 cases, of which 3 were malignant., Conclusions: Contrast-enhanced 3D power Doppler angiography is feasible in patients with suspicion of prostate cancer who are scheduled for prostate biopsies. The sensitivity of power Doppler 3D imaging for the detection of prostate malignancy increased from 38% (5 of 13) to 85% (11 of 13) after administration of intravascular microbubble contrast (Levovist), and specificity was found to be 80% (4 of 5) for both imaging modalities. Thus, the use of Levovist when combined with the power Doppler display mode and 3D image reconstruction offers a promising new research area that might prove useful in prostate cancer detection in the future.

Background: Despite good results of high-energy transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia, it is still difficult to predict the response to treatment on an individual basis. Besides clinical baseline parameters, intrinsic histological parameters are suggested to play a role in the response variance after TUMT. In this study we analyzed histological parameters (vessel density and epithelium-stroma (E/S) ratio) in patients who were selected for high-energy TUMT and related these parameters to clinical outcome., Methods: We treated 42 patients with high-energy TUMT, who prior to treatment agreed upon ultrasonographic investigation of the prostate in combination with biopsies of the peripheral and transitional zones of the prostate. For all separate biopsy locations, the histological stained prostate slides were morphometrically quantified with computer assistance and analyzed for E/S ratio and vessel density. Response to treatment was measured by using standardized response evaluation criteria and was correlated with histological outcome., Results: The E/S ratio in the inner gland biopsies tended to be higher in the good response group compared to the very poor responders. Furthermore, a clear trend was seen towards a lower vessel density in good responders. Large prostates and prostates with a high E/S ratio responded well to the high-energy thermotherapy., Conclusions: Histopathological parameters of the prostate tend to be moderately predictive for clinical response in this research population. Poor responders appeared to have a somewhat higher vessel density in all prostate biopsy sides, and there was also a trend towards a lower E/S ratio in these patients.

Interstitial laser coagulation (ILC) treatment is a recent technique in the treatment of BPH that is evolving rapidly. The results of a prospective randomised study vs transurethral resection of the prostate (TURP) is presented as well as results of patients treated with a temperature sensing laser system. The first study included 44 patients treated in a prospective randomised study (randomisation ILC vs TURP=2:1) comparing changes in objective and subjective parameters. In the second part of the study the outcome of the treatment of 34 patients with BPH using ILC performed with a temperature-sensing laser system are presented. The clinical outcome at 12, 26, 52 and 104 weeks was evaluated with symptom scores, quality of life measures, changes in voided volume, post void residual, and peak flow rate. In addition changes in prostate volume and urodynamic parameters at half a year follow-up are presented. In this randomised study patients improved markedly at any time during follow-up. In the ILC group there was a significant and persisting subjective improvement whereas the improvements in the TURP group were even more significant. The changes in voiding parameters, including changes in pressure-flow parameters, are superior in the TURP group compared to the changes in the ILC group. The retreatment rate for the ILC group is 21% compared to 7% in the TURP group, no patient with incontinence was documented in either group, while only one patients in the TURP group developed a urethral stricture. In the second part of the study, the clinical improvements following laser therapy using the temperature sensing treatment mode were more pronounced in voiding parameters when compared to those of the randomised laser group. Lower energy interstitial laser treatment of the prostate results in a significant improvement of all clinical parameters that are inferior to improvement following transurethral resection of the prostate. When using a temperature sensing system, the objective results of laser treatment improved and seem to be more durable.

Background: High-intensity focused ultrasound (HIFU) consists of focused ultrasound waves emitted from a transducer that are capable of inducing tissue damage. Experimental studies have shown clear damage of malignant tissue exposed to HIFU, but knowledge of in vivo effects is limited. We studied the safety and efficacy of HIFU in patients with a T1-2 N0) M0 prostate carcinoma., Methods: HIFU treatment was performed under general anesthesia with the Ablatherm device (Technomed Medical Systems, Lyon, France), 7-12 days prior to radical prostatectomy. Only the lobe in which carcinoma was confirmed was treated. The radical prostatectomy specimen was examined histopathologically, and the changes were compared with treatment goals., Results: So far, 9 patients have been treated. On histology, a sharp delineation was noted between areas treated with HIFU and untreated areas. On the dorsal border, however, incomplete destruction of tissue was noted, and in 2 cases a small residual tumor was seen in this region. In all cases complete necrosis was seen in the treated region., Conclusions: Histology reports of radical prostatectomy specimens of patients operated 7-12 days after HIFU treatment showed marked and complete necrosis in the treated area. Due to incomplete tissue destruction at the dorsal side, however, a small focus of residual vital tumor was found in 2 of 9 patients.

In this study we analyzed the individual value of baseline parameters to predict the outcome of high energy transurethral microwave thermotherapy in the treatment of patients with lower urinary tract symptoms and benign prostatic hyperplasia. Two hundred and forty-seven patients with symptomatic benign prostatic hyperplasia were treated with high energy microwave thermotherapy using the software 2.5 (Prostatron). Mean age at the time of treatment was 66.3 (s.d. 8.2) y, the mean prostate volume 57.0 (s.d. 25.2) cc and the mean energy applied was 159 (s.d. 40) KJ. Multi variable analysis on baseline parameters was performed to evaluate their predictive value for response using the WHO-response evaluation criteria for IPSS, maximum flow and urodynamic obstruction (linPURR). At 1 y follow-up a 57% increase in maximum flow and a 59% decrease in symptom score was noticed following high energy transurethral thermotherapy. The percentage of good responders varies between 12% and 34% depending on the stratification (IPSS, Q(max) and linPURR), the percentage of intermediate responders in these categories varies between 17% and 60% and the percentage of poor responders varies between 20% and 49%. Independently predictive baseline parameters for poor response were patients' age, prostate size and grade of bladder outlet obstruction (BOO). The total amount of energy delivered during treatment is also correlated with response. For the case selection for high energy transurethral microwave thermotherapy three baseline parameters can be identified which predict response for at least one response evaluation criterium: age, prostate size, grade of bladder outlet obstruction (BOO) and total amount of TUMT-energy. Especially the total amount of TUMT-energy is strongly predictive for all three response evaluation criteria, which suggests an important contribution of other mechanisms such as vascularisation and tissue composition to the outcome of high energy TUMT treatment.

Objective: To evaluate the responsiveness of the ICSmale questionnaire to the outcome of treatments for lower urinary tract symptoms (LUTS)., Patients and Methods: Consecutive men aged >45 years attending 23 urology centres in 12 countries, with symptoms suggestive of bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), were recruited to Phase I of the International Continence Society (ICS)-'BPH' study. In Phase II of the ICS-'BPH' study, 355 men in 15 centres in nine countries were followed up, having proceeded to treatment according to clinical practice. All men completed the ICS-'BPH' study questionnaire at baseline and follow-up, including the ICSmale which concerns LUTS and related problems., Results: Patients included in Phase II were similar to those in Phase I according to age and levels of baseline symptoms. Patients received a range of treatments: 32% TURP, 29% drug therapies, 20% watchful waiting, 9% minimally invasive therapies and 10% 'others' (including open prostatectomy). For patients who underwent TURP, most LUTS, including voiding and filling symptoms, were highly statistically significantly better at follow-up than at baseline (P<0.0001). For drug, minimally invasive and 'other' treatments, fewer LUTS were highly statistically significantly better. For those undergoing watchful waiting, no symptoms were significantly different between baseline and follow-up., Conclusion: The ICSmale questionnaire, in addition to being psychometrically valid and reliable, is responsive to change in outcome.

Objectives: To evaluate the relation between the American Society of Anesthesiologists (ASA) classification and response to transurethral microwave thermotherapy (TUMT) in patients with lower urinary tract symptoms and benign prostatic hyperplasia (BPH)., Methods: Two hundred forty-seven patients with symptomatic BPH treated with high-energy TUMT were scored retrospectively for ASA status. Student's t test was used to determine differences in improvement at each point of follow-up between patients classified as ASA 1 or 2 and patients classified as ASA 3 or 4. Logistic regression analysis was performed to assess the predictive value of ASA status for response using the World Health Organization response evaluation criteria for International Prostate Symptom Score, maximal flow rate, and urodynamic obstruction., Results: There was a significant improvement in objective and subjective parameters at 12, 26, and 52 weeks of follow-up in both ASA 1 and 2 patients and ASA 3 and 4 patients. There was no difference in objective and subjective improvement between both groups at each point of follow-up. Objective and subjective improvement in ASA 3 and 4 patients with cardiovascular disease and ASA 3 and 4 patients with noncardiovascular disease was the same, although patients with cardiovascular disease received less energy during TUMT. Using logistic regression analysis, ASA classification was not predictive of response after high-energy TUMT., Conclusions: There is no relation between ASA classification and outcome after high-energy TUMT. Because these patients are considered at high risk of perioperative complications and postoperative morbidity, TUMT could contribute considerably to the treatment of BPH in this specific group of patients.

Purpose: We evaluate changes in sexual function in patients treated with high energy transurethral microwave thermotherapy compared to transurethral resection of the prostate., Materials and Methods: A total of 147 patients randomized to undergo transurethral microwave thermotherapy or transurethral resection of the prostate were asked to complete a self-administered questionnaire evaluating sexual function before, and 3 and 12 months after treatment. The questionnaire dealt with such items as social status, libido, quality of erection, ejaculation and overall satisfaction of sexual functioning., Results: There was a statistically significant improvement of micturition in both groups. The improvement in the transurethral prostatic resection group was significantly better than in the transurethral microwave thermotherapy group. Antegrade ejaculation occurred at 3 months following treatment in 27% of the transurethral prostatic resection group compared to 74% of the transurethral microwave thermotherapy group and at 1 year in 37 and 67%, respectively. Significantly more patients undergoing transurethral prostatic resection (36%) had changes in sexual function compared to the transurethral microwave thermotherapy group (17%). The transurethral microwave thermotherapy group was more satisfied with the sex life. Of these patients 55% graded sex as very satisfying compared to 21% in the transurethral prostatic resection group. The severity of symptoms was not correlated with sexual function in this study. In general, older patients had sexual dysfunction more often, while younger patients had pain during sexual activities more frequently., Conclusions: Although clinically less effective, high energy transurethral microwave thermotherapy is a better therapeutic option than surgery for patients who want to preserve sexual function. In particular ejaculation is often preserved after transurethral microwave thermotherapy while there is significant deterioration following transurethral prostatic resection. In general, older patients have greater sexual dysfunction.

Tenascin (tenascin-C), a mesenchymal glycoprotein, is expressed in many tissue remodeling processes. We evaluated tenascin expression during androgen-deprivation-related involution of the rat prostate. At set intervals following castration and subsequent testosterone repletion, prostates were removed in 30 adult rats. Each prostate was immunostained with a polyclonal antiserum against rat tenascin and keratin antibodies specifically directed against exocrine basal cells and luminal cells in the prostate glandular structure. Morphologic impressions were semiquantatively evaluated using a computer-assisted image analysis system. Rat prostates showed a transient increase in the periglandular tenascin expression directly following castration that reached a maximum at day 3. At day 6, tenascin expression was similar to control prostates. This was accompanied by a decrease of cells in the luminal cell layer. The weakest tenascin immunoreactivity was noted on day 14 after androgen withdrawal. This process was reversed by androgen repletion. This study shows that in the rat prostate tenascin expression may be androgen dependent and that during androgen deprivation-related involution tenascin expression is probably associated with tissue remodeling by stromal-epithelial interactions.

Objectives: To assist urologists in selecting patients for high-energy transurethral microwave thermotherapy (TUMT) on the basis of baseline characteristics., Methods: Two hundred forty-seven patients with lower urinary tract symptoms and benign prostatic hyperplasia were treated with high-energy TUMT using the Prostatron device, software version 2.5. To evaluate outcome at 26 weeks, the World Health Organization response evaluation criteria were used. Multiple logistic regression models were created to identify the predictive value of baseline parameters and total amount of energy used. In addition, receiver operating characteristic curve and the best cutoff point for the prediction of a good response of each criterion under the condition of equal "costs" of misclassification to cases and noncases were calculated., Results: For each of the three response evaluation criteria, graphs are presented to determine whether high-energy TUMT using the Prostatron can be justified. Only the total amount of energy delivered by the device has a major impact in all three criteria used., Conclusions: Graphs have been constructed from our analysis to assist urologists in making clinical recommendations for treatment on the basis of the expected outcome when using high-energy TUMT.

Objectives: A feasibility study to evaluate whether analysis techniques adapted from X-ray angiography can be used to analyze the transient enhancement of prostate blood flow patterns in color Doppler maps as obtained after administering ultrasound contrast agents., Methods: Injections of ultrasound contrast agents were given to dogs and humans, and color Doppler blood flow patterns in fixed transverse sections through the prostate were recorded on video tape. Computer assistance of Doppler signals over time is used to evaluate the transient enhancement of flow patterns obtained with contrast-enhanced Doppler ultrasound. Results are compared to indicator dilution curve theory as used in, e.g., X-ray angiography., Results: Administering a contrast agent to improve color Doppler evaluation of prostate blood flow resulted in clear enhancement of Doppler signal intensities without unwanted side effects. Using the computer, the perfused area of the prostate could be obtained quantitatively over time showing profiles of individual heartbeats. Averaging the perfused area over one heartbeat resulted in an indicator dilution curve, and correlation with dilution theory indicated the feasibility of applying wash-in and wash-out analysis of contrast agents in color Doppler images., Conclusion: Frame-by-frame interpretation by the computer indicated the feasibility of analyzing the transient enhancement of blood flow visibility in the Doppler image over time using techniques such as wash-in and wash-out time. This technology provides researchers in the field of ultrasound evaluation of the prostate the opportunity to apply a new diagnostic tool, contrast angiosonography, in their research. This method for analysis of prostatic blood flow can be helpful in any application that affects the blood supply of the prostate such as heat treatments and hormonal treatments.

Prostate and urinary bladder cancer are the most frequently encountered malignancies of the urinary tract. Appropriate use of the different imaging techniques is crucial for accurate assessment of prognosis and for the development of appropriate treatment planning. Especially determination of local tumor extension and detection of nodal or bone metastases is extremely important. In this regard MR imaging is the most promising imaging technique. Therefore, in this review its role in staging these malignancies is evaluated and compared with clinical staging, and other imaging techniques. Finally, future developments, such as new sequences, new contrast agents, the role of surface coils and MR-guided biopsy, are considered. Also, the preferred radiological approach is discussed.

To evaluate the reproducibility in maximum urinary flow rate (Qmax) in men with lower urinary tract symptoms (LUTSs) and to determine the number of flows needed to obtain a specified reliability in mean Qmax, 212 patients with LUTSs (mean age, 62 years) referred to the University Hospital Nijmegen, with various degrees of obstruction on pressure-flow studies, used a portable home-based uroflowmeter with 12 disposable beakers. Voided volume and maximum flow rate were recorded continuously during micturition. Flows with voided volumes of at least 100 ml and without possible artifacts were included. All analyses were repeated while excluding flows with voided volumes <150 ml. A coefficient of variation (CV) was calculated for each patient. The CV represents the standard deviation relative to the mean. All individual CVs were subsequently pooled into a population mean CV. This parameter was used to estimate the number of flows required to obtain a mean Qmax with specified reliability for an individual patient. All analyses were repeated, while successively excluding the first, the first two, and the first three flows, to assess a possible learning curve. A total of 1,854 flows was available for analyses, yielding an average of nine flows per patient. Mean Qmax was 13.2 ml/sec; the mean CV was 24%. To allow, for instance, a 10% deviation from the true mean Qmax (e.g., 15 ml/s +/- 1.5 ml/s), approximately 25 flows are necessary. The actual number of flows needed is in fact even higher due to the presence of small and artifactual flows. Using a 150 ml volume cutoff point, somewhat fewer flows are required, but the total number of flows needed (that is, valid, small, and artifactual flows) increases. There was no evidence of a learning curve. The boundaries of a confidence interval around a single Qmax measurement that is likely to contain the true mean Qmax, lie approximately 50% below or above that single Qmax measurement. To reduce this proportion down to 10%, approximately 25 flows are needed. Thus, to obtain reliable mean Qmax values, considerably more flows are required than are normally performed in urologic practice.

Recently, laser treatment of the prostate has been added to the urologist's armamentarium for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH). Until now, limited data on long-term outcome are available notwithstanding the fact that such information is crucial in determining the ultimate role of laser prostatectomy in the treatment of BPH. We now have 3-year data of a comparative study using the Urolase and Ultraline fiber in Nd:YAG sidefiring laser prostatectomy. The study was performed to compare laser prostatectomy using a pure coagulation (Urolase fiber) and a combination of a coagulation and vaporization (Ultraline fiber). In a period of 15 months, 93 men were randomized for laser treatment with the Ultraline fiber (N = 44) or the Urolase fiber (N = 49). Symptom scores, maximal uroflow, postvoiding residual volume, and sexual history were noted over a 3-year period. Adverse events and retreatments were also recorded. The mean postoperative catheterization time was 18 days, without significant difference between the two groups. After 3 years, we demonstrated a durable improvement in maximal flow rate, from 7.8 to 13.9 mL/sec in the Urolase group and from 7.9 to 13.6 mL/sec in the Ultraline group. In both groups, however, a considerable decrease in the maximal flow rate was noted after 3 years compared with 3 months after treatment, from 18.7 to 13.9 mL/sec in the Urolase group and from 20.0 to 13.6 mL/sec in the Ultraline group. The symptom scores showed marked and lasting improvement. The postvoiding residual urine volume became very low in the early postoperative period but did significantly increase after 3 years; nevertheless, it was still only 50% of the preoperative value. Although after 3 years, the maximal uroflow rate was still significantly improved compared with baseline, a considerable decrease was noted when compared with the early postoperative value. The same considerable and lasting improvement in subjective outcome (symptom scores) was seen in both groups. Although the Ultraline fiber also causes vaporization of prostatic tissue, no differences could be noted in the clinical outcome obtained with the two fibers.

Objective: To evaluate the combination of patient age, prostate size, grade of outlet obstruction and total amount of energy, all independent predictive variables of treatment outcome in patients with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) treated with high-energy transurethral microwave thermotherapy (HE-TUMT), and thus provide nomograms for predicting treatment outcome after HE-TUMT., Patients and Methods: Between October 1993 and July 1996, 247 patients with LUTS and BPH were treated with HE-TUMT using the Prostatron device, software version 2.5 (EDAP Technomed, Lyon, France). The World Health Organisation Response Evaluation Criteria were used to evaluate the outcome. Patient age, prostate volume, total amount of energy and grade of outlet obstruction were categorized using the Akaike information criterion (AIC). The probabilities of a good/intermediate vs a poor response at 26 weeks according to the AIC were calculated., Results: Nomograms are presented providing the estimated probability (95% confidence interval) for a good/intermediate response of the evaluation of the International Prostate Symptom Score at 26 weeks by categories of prostate volume, total amount of TUMT energy and age, and of maximum urinary flow rate by categories of bladder outlet obstruction (linear passive urethral resistance ratio, linPURR) and total amount of energy, and of linPURR by categories of prostate volume and total amount of energy. The total amount of energy appeared to have the most impact in the prediction of good/intermediate and poor response in all three response evaluation criteria., Conclusions: These nomograms may assist urologists in making clinical recommendations for the treatment of men with LUTS and BPH using HE-TUMT.

Objective: To explore the relationship between uroflow variables and lower urinary tract symptoms (LUTS): to define performance statistics (sensitivity, specificity, positive and negative predictive values) for maximum urinary flow rate (Qmax) with respect to bladder outlet obstruction (BOO) at various threshold values; and to investigate the diagnostic value of low-volume voids., Patients and Methods: The study comprised 1271 men aged between 45 and 88 years recruited from 12 centres in Europe, Australia, Canada, Taiwan and Japan over a 2-year period. Symptom questionnaires, voiding diaries, uroflowmetry and pressure-flow data were recorded. The relationship between uroflow variables and symptoms, Qmax and BOO, and the diagnostic performance of low volume voids were analysed., Results: The relationship between symptoms and uroflow variables was poor. The mean difference between home-recorded and clinic-recorded voided volumes was -48 mL. Qmax was significantly lower in those with BOO (9.7 mL/s for void 1) than in those with no obstruction (12.6mL/s; P<0.001) and Qmax was negatively correlated with obstruction grade (Spearman's correlation coefficient -0.3, P<0.001), even when controlling for the negative correlation between age and Qmax (Spearman's partial correlation coefficient -0.29, P<0.001). A threshold value of Qmax of 10 mL/s had a specificity of 70%, a positive predictive value (PPV) of 70% and a sensitivity of 47% for BOO. The specificity using a threshold Qmax of 15 mL/s was 38%, the PPV 67% and the sensitivity 82%. Those voiding <150 mL (n=225) had a 72% chance of BOO (overall prevalence of BOO 60%). In those voiding >150 mL the likelihood of BOO was 56%. The addition of a specific threshold of 10 mL/s to these higher volume voiders improved the PPV for BOO to 69%., Conclusion: While uroflowmetry cannot replace pressure-flow studies in the diagnosis of BOO. it can provide a valuable improvement over symptoms alone in the diagnosis of the cause of lower urinary tract dysfunction in men presenting with LUTS. This study provides performance statistics for Qmax with respect to BOO: such statistics may be used to define more accurately the presence or absence of BOO in men presenting with LUTS, so avoiding the need for formal pressure-flow studies in everyday clinical practice, while improving the likelihood of a successful outcome from prostatectomy. This study also shows that low-volume uroflowmetry can provide useful diagnostic information and that, as such, the data from such voids should not be discarded.

Objectives: To review the current clinical practice concerning prostate biopsies and indications for prostate biopsies and to study the value of biopsies in grading and staging of prostate cancer., Methods: The literature from 1990 onwards was reviewed systematically. A selection out of the huge number of publications concerning the subject was made based on the relevance of the study (e.g., number of patients, study design)., Results: Transrectal ultrasound-guided biopsies have become a routine procedure in urological practice and can be performed safely. Antibiotic prophylaxis is recommended generally. Sextant biopsies should be performed when no lesion is visible or added to lesion-directed biopsies in case of a visible lesion. The indications for biopsies and for repeat biopsies are discussed. The indication for biopsies remains a problem in spite of prostate-specific antigen and prostate specific antigen derived indexes and in spite of new imaging techniques. The value of prostate biopsy in grading and staging is limited, and care should be taken not to base treatment decisions on prostate biopsy results only and not to compare treatment results based on biopsy data., Conclusions: Prostate biopsies have become a routine procedure in urology. Although very helpful in many cases, their limitations should be kept in mind. More efforts will have to be made to reduce the (too) large number of negative biopsies by improvement of imaging techniques and development of more sensitive and specific tumor markers.

Objectives: To obtain information on compliance to therapy and study its effect on recurrences. Over the past 20 years, a selective therapy protocol has been formed for prevention of urolithiasis recurrence. Many studies have been performed on the effectiveness of this therapy, but compliance has never been examined., Methods: Data were abstracted from 177 medical records of patients who were seen at the outpatient clinic between 1985 and 1994. At that time, they were advised to follow a specific therapy regimen (high fluid intake, medication, and/or specific diet) on the basis of the outcome of a standardized metabolic evaluation., Results: Thirty-six percent of the study population was still compliant to the prescribed therapy after a mean period of 5.3 years of follow-up. Therapy-compliant patients were older and had had more treatments, more lithiasis-related complaints, and more frequent follow-up visits. These characteristics suggest that patients' awareness of their disease might improve compliance. Survival analyses showed that patients can be classified into two groups characterized by the frequency of stone formation: a single stone episode versus frequent periods of stone formation. It appeared that the stone recurrence rate was twice as high among patients with a history of frequent stones compared with patients with a single stone episode, even though compliance to therapy seemed lower in the latter group., Conclusions: The usefulness of urometabolic evaluation and subsequent therapy advice seems questionable. Compliance to a life-long therapy is very low after a relatively short follow-up period. This study also suggests a prognostic classification based on stone rate.

Background: Tenascin (tenascin-C) has been suggested to be associated with active epithelial-stromal interactions. We evaluated tenascin expression in tissue remodelling processes presumably associated with PIN and prostate carcinoma (PCa)., Materials and Methods: Tenascin immunoreactivity was evaluated in 38 PIN lesions (low-grade = 5, high-grade = 33) from 27 paraffin-embedded PCa specimens, and compared with expression in pre-existent (normal) prostate, benign prostatic hyperplasia (BPH), and PCa., Results: Periepithelial stromal tenascin expression was low in low-grade PIN, and similar to normal glands and BPH, whereas expression in high-grade PIN was high and partly overlapped that of well-/moderately differentiated PCa. High-grade PCa usually expressed little, if any tenascin., Conclusions: The variable periglandular tenascin expression in high-grade PIN may reflect the biologic behaviour of this lesion, and may be indicative of variable levels of tissue remodelling. In well/moderately differentiated PCa tenascin expression levels may be an indicator of tumour progression.

Three types of sidefiring laser fibers (34 Urolase, 20 Ultraline, and 114 Prolase II) were visually inspected after a laser prostatectomy, and transmission measurements were performed using a power meter (Aquarius). The results were correlated with the clinical outcome. Despite differences in the amount of loss in transmission for the fibers used, we could not establish any significant effect on clinical outcome measures, such as improvement in maximal flow rate or symptom score. The visual aspect of the Urolase fibers was significantly related to the amount of transmission loss, whereas no such relation was found for the other two types of fibers. Prostate size and the total amount of energy delivered by the laser source also did not correlate with the clinical outcome. To determine the relation between the energy absorbed by the prostate and clinical outcome, a large number of patients must be evaluated, and any factor that can be controlled needs to be monitored. For the latter, the power meter as presented here is a useful complementary tool.

Purpose: We evaluate long-term results of lower energy transurethral microwave thermotherapy (Prostasoft 2.0*) and identify pretreatment characteristics that predict a favorable outcome., Materials and Methods: Between December 1990 and December 1992, 231 patients with lower urinary tract symptoms were treated with lower energy transurethral microwave thermotherapy. Subjective and objective voiding parameters were collected from medical records and a self-administered questionnaire. Kaplan-Meier plots were constructed to assess the risk of re-treatment., Results: Of the patients 41% underwent invasive re-treatment within 5 years of followup and 17% were re-treated with medication. The re-treatment-free period was somewhat longer in patients with a peak flow rate greater than 10 ml. per second, a Madsen score 15 or less, a post-void residual volume 100 ml. or less and age greater than 65 years at baseline. Prostate volume did not modify the outcome. No incontinence was caused by transurethral microwave thermotherapy, 8% had recurrent urinary tract infection and 8% had retrograde ejaculation. Only 1 patient had a urethral stricture after transurethral microwave thermotherapy., Conclusions: At 5 years after transurethral microwave thermotherapy 41% of the patients received instrumental treatment. Patients with a lower Madsen score and lower residual volume, and those with higher peak flow and age were somewhat better responders to lower energy transurethral microwave thermotherapy.

Objective: To evaluate the structural relationship of the distribution between tenascin (tenascin-C, an extra-cellular matrix glycoprotein involved in stromal-epithelial interactions in both normal and pathological conditions) and laminin, an important component of the basement membrane, in normal and neoplastic human prostate, and to establish whether changes in the basement membrane are accompanied by changes in tenascin staining., Materials and Methods: Seventy-five snap-frozen prostate samples representing normal glands, nodular benign prostatic hyperplasia and prostate carcinoma were stained for tenascin. From these, 15 samples were selected for dual-immunofluorescence staining and a confocal laser scan microscope was used to simultaneously visualize tenascin and laminin immunoreactivity., Results: Tenascin was expressed in the extracellular matrix, mainly at the periphery of the glands, in tumour foci and blood vessels. In cases with intact basement membranes, e.g. normal glands and hyperplastic lesions, tenascin expression was weak. Low- and moderate-grade tumours were characterized by strong tenascin expression, while laminin expression was weak and/or showed discontinuities, indicating disturbances in basement membrane composition. High-grade tumours had sparse tenascin staining and a marked loss of laminin immunoreactivity., Conclusion: These results indicate that periglandular tenascin expression correlates with the integrity of the basement membrane in the human prostate. By influencing stromal-epithelial interactions, tenascin may play a role in maintaining tissue homeostasis in the prostate.

Purpose: We present a critical evaluation of the use of ultrasound for prostate disease examination in urological practice, and provide perspectives on ultrasound applications that may become important for the future evaluation of prostate problems., Materials and Methods: Based on an evaluation of clinical data in cases suspicious for prostatic malignancy, we addressed the apparent shortcomings of transrectal ultrasound for accurately diagnosing prostate cancer. Future applications presented in the literature were noted., Results: Evaluating the ultrasound data in cases suspicious for malignancy indicated that imaging has little advantage over digital rectal examination for detecting malignant areas. The new applications of ultrasound that hold great promise for use in the urology clinic include the injection of contrast agents to obtain information on blood supply, temperature estimation for the noninvasive assessment of temperature distributions during heat treatment and a therapeutic application for local treatment of prostate cancer., Conclusions: While differential diagnosis with ultrasound appears to result in disappointing sensitivity and specificity values, its use in volume measurement and biopsy guidance is unquestioned. The development of new applications may improve the clinical value of ultrasound in urological practice. The application of ultrasound contrast agents for the detection and clinical staging of prostate cancer is especially promising. Future research will indicate whether the promise evolves in clinical applications.

Background: The secretory acini of the adult human prostate contain basal, luminal, and intermediate types of exocrine cells. Intermediate cells are thought to play an important role in normal growth and neoplastic transformation. In this study we investigated whether this cell type is present in early stages of prostate development, using keratin antibodies specific for them., Methods: Autoptic tissue from 11 prepubertal and 5 normal adult prostates was immunohistochemically stained with four keratin antibodies capable of specifically detecting basal, luminal, or intermediate cell types., Results: Morphologically, in fetal prostate cells differentiation was often not evident. However, basally located cells usually displayed a basal-cell keratin-phenotype. Morphologically similar cells with more luminal localization expressed keratins typical of luminal cells, or of intermediate cells., Conclusions: 1) In early stages of prostate development, cells with intermediate keratin-phenotype can be identified. 2) Their large numbers comply with a hierarchical pathway of cellular differentiation from basal to luminal cells. 3) The presence of intermediate cells at such an early fetal age may reflect their regulatory function in prostate development.

Objective: We investigated an algorithm to detect grey level transitions with multiple scales of resolution to improve edge detection and localisation in ultrasound images of the prostate., Introduction: We had developed a non-analytical operator for prostate contour determination implemented with minimum and maximum filters and locate edges. We implemented a technique for improved determination of boundary parts in prostatic ultrasound images by adjusting the edge detection parameter to signal information., Methods: First the influence of prefilter settings and edge detection parameters is investigated in a test image and a real ultrasound image. Then, local standard deviation is used to identify or fewer homogeneous regions that are filtered with course resolution, while areas with larger deviation that grey level transitions occur, which should be preserved using smaller filter sizes to improve edge localisation., Results: Analysis of images with different filter sizes indicated that areas are merged for increasing filter sizes: less pronounced edges disappear or displace for larger filters. Two scales of resolution lead to an improved localisation of edges when smaller filter sizes are used in areas with an increased local standard deviation., Conclusions: This paper illustrates an edge detection method suitable as pre-processing step in interpretation of medical images. By adapting input parameters to signal information, object recognition can be applied in images from different imaging modalities. Also, disadvantages are discussed, resulting in a new application combining a localisation algorithm to find the initial contour and a delineation algorithm to improve the outlining of the resulting contour.

Objective: To evaluate the outcome and durability of high-energy transurethral microwave thermotherapy (HE-TUMT) in comparison with transurethral resection of the prostate (TURP)., Patients and Methods: Fifty-two patients with BPH and lower urinary tract symptoms were randomized and treated either by TURP (21 patients; mean prostate volume 45 mL, SD 15) or HE-TUMT (31 patients, mean prostate volume 43 mL, SD 12). Long-term results were obtained at a mean (SD) follow-up of 2.4 (0.5) years., Results: During the follow-up, the mean symptomatic improvement stabilized at 56% after TUMT and 74% after TURP. The mean maximum urinary flow rate increased by 62% after TUMT and 105% after TURP. Before treatment, 78% of patients in the TURP group were obstructed according to urodynamic investigation and after treatment, 14% remained obstructed. In the TUMT group, 67% of patients were obstructed before treatment and 33% remained so afterward. Six patients (19%) underwent TURP after TUMT (four after 1 year) and two patients were also treated with medication. One patient underwent a bladder neck incision after TURP to treat bladder neck sclerosis. Three patients were not satisfied with the outcome after the additional TURP., Conclusion: Both treatment modalities show good symptomatic and objective results at > 2 years of follow-up. Most re-treatments were performed > or = 1 year after treatment and were based on subjective findings.

The urodynamic profiles of 97 patients with benign prostatic hyperplasia undergoing low-energy transurethral microwave thermotherapy (TUMT) for lower urinary tract symptoms were analysed using the Abrams/Griffiths nomogram, the urethral resistance algorithm, the linPURR, Schäfer nomogram, and the CHESS classification. A significant clinical response was seen for the whole group, as shown by changes in symptom score, free flow rate, and residual urine. The best symptomatic response was identified in patients in whom obstruction was present, whatever the classification used. Only the two-dimensional CHESS classification was found to predict a group of patients with a better response in both symptoms and objective variables. Obviously, a better response from TUMT can only be predicted by a classification system that identifies the independent variables of footpoint and slope of the PURR. The CHESS classification was the only one of those studied that satisfactorily identified these two parameters and could be used as a system of case selection for this minimally invasive treatment.

Objectives: To determine the efficacy and costs of extracorporeal shock-wave lithotripsy (ESWL) compared with ureteroscopy (URS) in the treatment of mid- and lower ureteric calculi., Patients and Methods: The records of patients treated primarily by ESWL and URS were analysed retrospectively. Treatment with ESWL included 63 patients (42 men and 21 women, mean age 52 years, range 23-78, 19 mid- and 44 lower ureteric calculi). All patients received 4000 shock waves at a mean energy setting of 18.1 kV. URS was used in 105 patients, with a 7.2 F miniscope or the 7.1 F flexible scope. Stones were fragmented with a pulsed-dye laser lithotripter at 504 nm and a power of up to 130 mJ (mean 53 mJ) using a 200 or 320 microns fibre. All ureteroscopies were performed with the patient under general (n = 17) or spinal (n = 87) anaesthesia in a mean treatment duration of 34 min. Stones were located in the mid-ureter in 24 patients and in the lower ureter in 80. The outcome was assessed by stone-free rates, re-treatment rates, time to become stone-free, complication and costs., Results: ESWL for mid- and lower ureteric calculi resulted in a success rate of 90% and 81%, respectively, compared with 96% and 99% for URS. However, patients treated with URS were stone-free within 2 days, whereas patients in the ESWL group required up to 4 months. The best results for ESWL were achieved with stones of < 50 mm2. The costs of URS were higher than those for ESWL., Conclusions: ESWL provides a noninvasive, simple and safe option for the management of mid- and lower ureteric calculi, provided that the stones are < 50 mm2; larger stones are best treated by URS.

Despite the lack of evidence in the literature for close relationships between lower urinary tract symptoms and bladder outlet obstruction, the majority of urologists rely on symptomatology when selecting patients for prostatic surgery. We investigated the relationships between a wide range of lower urinary tract symptoms from the ICSmale questionnaire and the results of urodynamic pressure and flow studies. We evaluated 933 patients with lower urinary tract symptoms suggestive for bladder outlet obstruction from 12 countries who participated in the ICS-"BPH" study with the ICSmale questionnaire and urodynamic pressure and flow studies. Spearman rank correlation coefficients were obtained between symptoms and measures of bladder outlet obstruction. There was little or no correlation between a wide range of symptoms and the results of free uroflowmetry and pressure and flow studies. From symptoms alone, it is not possible to diagnose bladder outlet obstruction. Pressure and flow studies and symptom profiles measure different aspects of the clinical condition that should be viewed separately in the evaluation and treatment decision of the patient presenting with lower urinary tract symptoms.

Objectives: To evaluate a computerized method of artifact detection and correction of uroflow and compare the quantitative assessment of maximum flow obtained by the computer with visual correction by experts., Methods: A total of 90 randomly chosen flows was scanned into the computer whereafter automated artifact detection and correction was performed according to pre-established rules implemented in the software. Three experts visually corrected the flows using the same artifact detection and correction specifications as the computer. Measuring agreement between different methods of assessment of maximum flow was evaluated by calculating the difference and the standard deviation (SD) of the differences. The repeatability of assessing the maximum flow value by the computer and by expert 1 was assessed by calculating the difference between 2 readings and the coefficient of repeatability., Results: The coefficient of repeatability of maximum flow after detection and correction of artifacts by the computer (0.38 ml/s) was slightly better when compared with the coefficient of repeatability between 2 observations by 1 expert (1.12 ml/s). The interobserver variation for the quantitative assessment of maximum flow appeared to be great. A total of 51% of the maximum flow values assessed by expert 2 was 1 ml/s or more greater than those assessed by expert 1. When comparing the results of the computer with those of the experts, the mean value of maximum flow from expert 1 was 0.71 ml/s smaller than the computer value (p < 0.01), the mean value from expert 2 was 0.53 ml/s greater (p < 0.01) and the mean value from expert 3 was not significantly different (0.25 ml/s greater). The SD of maximum flow after correction by the computer was 0.3 ml/s smaller than the SD of the raw data from the flowmeter and the corrected values by 2 experts., Conclusions: Computerized artifact detection and correction eliminates an important fraction of the variability of manually corrected maximum flow values. This may lead to smaller sample size requirements, especially in studies where the primary objective is to assess a small (+/- 1 ml/s) difference in mean maximum flow between groups.

This paper reviews the available data on low- and high-energy transurethral microwave thermotherapy (TUMT) in the treatment of patients with benign prostatic hyperplasia (BPH). Furthermore, it provides a perspective for this minimally invasive treatment modality in the selection of patients and in future developments. In evaluations of the two software modalities, several clinical studies have proved them to be effective. Whereas the lower-energy software seems to be the better choice for treatment of patients with lower urinary tract symptoms who have a lower grade of outlet obstruction and a smaller prostate, the higher-energy mode should be used to deobstruct and can be used in patients with larger prostates and moderate to severe outlet obstruction. Although baseline parameters can be used to predict the response to treatment in the higher-energy software mode, the total amount of energy remains very important for the final outcome, and future efforts should be encouraged to quantify prostate vascularization and histology in relation to transurethral microwave heating. Furthermore, future developments should focus on shorter treatment times and minimization of morbidity.

Although various heat treatments of benign prostatic hyperplasia have shown promising results, their morbidity-particularly urinary retention-should not be underestimated. Temporary stents are an appealing solution to this problem. Some of these are removable, whereas others are biodegradable. The various stent designs and the early clinical results are reviewed. The authors believe that temporary stents will encourage the use of alternatives to transurethral resection.

This paper presents the current diagnostics of patients with prostate related problems (lower urinary tract symptoms) who visit the urology clinic. The diagnostic triad for prostate cancer detection is presented, consisting of a serum Prostate-Specific Antigen test, a digital rectal examination to palpate the prostate, and transrectal ultrasound of the prostate to visualise internal structures and guide the urologist in taking biopsies. The results of the tests for a biopsied population of 232 patients illustrate the shortcomings of the individual tests in predicting the presence of a malignancy. Biopsies are needed to prove or rule out prostate cancer in case of a suspicion. Future developments in early detection of prostate cancer are directed to improve the clinical use of the current diagnostic triad, and to identify new diagnostic tools.

Objective: To present and describe the validity and reliability of the International Continence Society-Benign Prostatic Hyperplasia study quality-of-life (ICSQoL) instrument, a new set of questions to assess the impact of lower urinary tract symptoms (LUTS) on quality of life (QoL) in middle-aged and elderly men., Patients and Methods: The study comprised 1271 consecutive men over the age of 45 years, attending urology departments in 12 countries, with LUTS and possible benign prostatic obstruction who were recruited to the ICS-'BPH' study (the clinic group); 423 ambulant men were recruited from a general practice in the UK to provide a community group. Each individual completed the ICS-'BPH' study questionnaire which includes six items addressing general and specific aspects of QoL (the ICSQoL). Content and construct validity were assessed by interviews with patients and by testing hypotheses within the study groups, e.g. the relationships with age, individual LUTS (as measured on the ICSmale questionnaire) and generic health status, as measured by the Short Form (SF-36) and EuroQol instruments. Reliability was assessed by measures of internal consistency and a test-retest analysis., Results: The ICSQoL items were easily understood by patients, were completed with low levels of missing data, and address some (but not all) concerns about the impact of LUTS on QoL. The ICSQoL items have good construct validity, showing expected differences between community and clinic samples, and expected relationships with each other and individual LUTS. Items had good test-retest reliability, but their internal consistency was poor, confirming that ICSQoL questions should not be combined into a score. General ICSQoL items were closely related with most domains of the SF-36 and the EuroQol., Conclusion: ICSQoL items may be used individually or as a group in research studies or in clinical practice.

Purpose: We evaluated the impact of lower energy transurethral microwave thermotherapy on quality of life and quality of sexual function in patients with benign prostatic hyperplasia (BPH)., Materials and Methods: A total of 50 patients with BPH were randomized to receive either lower energy transurethral microwave thermotherapy treatment (Prostasoft 2.0) or placebo treatment and followed for 26 weeks after treatment. All patients completed a Madsen symptom score and quality of life questionnaire to assess acceptability, daily activities, psychological well-being, social activities and improvement in quality of life. A sexual function questionnaire was used to assess changes in sexual function after microwave thermotherapy., Results: A significant difference in voiding parameters and symptom score was found between the transurethral microwave thermotherapy and sham groups. Maximum uroflow changed from 9.6 ml. per second at baseline to 13.9 ml. per second and from 9.9 ml. per second at baseline to 9.6 ml. per second at 26 weeks for transurethral microwave thermotherapy and sham groups, respectively. Madsen score improved from 13.2 to 5.3 for the transurethral microwave thermotherapy group and from 11.9 to 9.1 for the sham group. For quality of life measures, a statistically significant difference in favor of the transurethral microwave thermotherapy group was found only for the acceptability item. At baseline and after 26 weeks no statistically significant difference was observed between the 2 groups for Quality of Life measures documenting sexual function. However, almost 20% of patients treated by either transurethral microwave thermotherapy or sham claimed at 26 weeks after treatment that treatment had influenced sexual function., Conclusions: Although significant changes in objective and subjective parameters were found in patients after lower energy microwave thermotherapy, the change in quality of life was minimal. In addition to the minimal invasiveness of transurethral microwave thermotherapy, preservation of sexual function is appealing.

Objective: To report the initial results of the treatment of patients with benign prostatic hyperplasia using interstitial laser coagulation (ILC) performed with a temperature-sensing laser system., Patients and Methods: Twenty-five patients were treated using ILC and in 12, 78 temperature-power curves were recorded. The aim of the treatment was to maintain a temperature of 100 degrees C during the entire treatment cycle, using the temperature-triggered feed-back system. The time to reach the maximum temperature, the maximum temperature and the energy delivered were related to the location of the punctures within the prostate. The clinical outcome at 1 and 3 months was evaluated with symptom scores and uroflowmetry variables., Results: Heating at the apex seemed to require less energy to achieve and maintain higher temperatures than heating of the median lobe or base of the prostate. Patients improved markedly 1 and 3 months after treatment; the respective mean symptom scores improved from 20.6 before treatment to 9.4 and 6.9, the maximum urinary flow rates from 9.1 mL/s to 14.1 mL/s and 20.3 mL/s and the post-void residual volume decreased significantly from 71 mL to 31 mL and 11 mL. No significant complications (incontinence, impotence or haemorrhage requiring transfusion) occurred., Conclusion: The energy needed to achieve coagulation differed at sites within the prostate, depending on local circumstances. Good results were obtained using the tissue-adaptive laser system.

Objective: To determine the importance of the assessment of quality of life in patients who have undergone laser prostatectomy., Patients and Methods: Patients undergoing laser prostatectomy were evaluated using the International prostate symptom score (IPSS) questionnaire, uroflowmetry, post-void residual volume (PVR) measurements, and quality-of-life (QOL) and sexual function questionnaires., Results: In all, 103 patients were evaluated; there was an overall significant improvement in the mean IPSS, maximum flow, PVR and QOL score and no apparent subjective change in sexual function. There was a good correlation between the IPSS and the QOL score, but no correlation between the QOL score and the maximum flow rate, and only a weak correlation between the IPSS and the maximum flow rate., Conclusion: Laser prostatectomy significantly changed the patients' quality of life. This may be more important for the patient than the improvement in the voiding variables alone. In future (changes in) quality of life will probably contribute significantly to selecting patients with voiding complaints for particular treatments.

Objectives: To investigate if the circadian rhythm of urinary flow values varies within groups of patients with varying degrees of bladder outlet obstruction., Methods: A total of 170 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction used a home-based uroflowmeter and produced a total of 1670 correctly measured flows at home. These patients also underwent a screening program with free urinary flowmetry in the hospital and a urodynamic pressure and flow study., Results: There is a circadian variability in urinary flow values in men with higher grades of obstruction. These men have a higher peak urinary flow with a smaller voided volume and thus a shorter flow time in the early afternoon when compared with late evening, early morning, and the midnight to morning periods., Conclusions: This significantly greater maximum flow in the afternoon in men with higher grades of obstruction can be an important bias in studies where the primary end point is to assess a small improvement in maximum flow. Therefore, the circadian rhythm of uroflow has to be taken into account in the evaluation of the efficacy of treatment. Patients participating in clinical research studies should produce their urinary flow in the clinic always during the same time period, either in the morning or in the afternoon, and should not switch their appointment time.

Since 1993, we have treated patients having lower urinary tract symptoms and benign prostatic obstruction using the high-energy transurethral microwave thermotherapy (HE-TUMT) protocol (Prostasoft; software version 2.5). This study was conducted to investigate the outcome and durability of this treatment. A series of 301 patients with a mean prostate size of 56.4 cc were treated by HE-TUMT if they had a Madsen Symptom Score > or = 8, a maximum flow rate < 15 mL/sec, a voided volume > or = 100 mL, and a postvoiding residual volume < 350 mL. The prostate volume measured by transrectal ultrasonography was > or = 25 cc. Follow-up visits were scheduled at 12, 52, 78, and 104 weeks. Patients were stratified according to the response evaluation criteria set at the 3rd International Consultation on Benign Prostatic Hyperplasia. These response criteria were measured at 12 weeks. At 2 years, there appeared to be a better response in the bigger prostates. Irrespective of relief of outflow obstruction, a good symptomatic response was seen in both good and poor responders. Twenty-two patients were re-treated during the 2-year follow-up period: three underwent bladder neck incision, nine transurethral resection, two laser prostatectomy, one open prostatectomy, and seven additional medical therapy. At 2-year follow-up, HE-TUMT resulted in a durable good outcome in 93% of patients with an objective improvement rate of 42% and a subjective improvement rate of 65%. The best predictor of durability appeared to be the extent of relief of obstruction. Of the 96 bad responders in this group, 14 underwent retreatment, compared with 6 of the 100 good responders.

Objective: To determine if, in patients with lower urinary tract symptoms (LUTS), measurement of the transition zone (TZ) of the prostate by transrectal ultrasonography (TRUS) and the ratio between the TZ volume and total prostate volume (TZ index) correlates better with clinical and urodynamic investigations than total prostate volume alone., Patients and Methods: In total, 150 consecutive patients with LUTS underwent a standardized screening programme including the International Prostate Symptom Sore (IPSS), a physical examination, TRUS of the prostate and urodynamic investigations with pressure-flow studies. The total prostate volume and TZ volume were assessed from TRUS using the ellipsoid formula. Spearman's rank correlation coefficients were calculated between different prostate volume measurements and specific symptomatic and urodynamic variables., Results: The relationships between specific IPSS symptoms, symptom scores and the prostate volume measurements were not statistically significant except for one domain, nocturia, that appeared to be statistically significantly correlated with the TZ index (r = 0.25). The correlations for free flow, pressure-flow variables and prostate volume measurements were stronger, but only moderate at best. The highest correlations were between TZ volume and the linear passive urethral resistance obstruction category, urethral resistance factor and detrusor pressure at maximum flow (r = 0.43, 0.44 and 0.40, respectively). The differences between the correlations of prostate volume and TZ index and these variables were small (r = 0.39, 0.38 and 0.37, respectively for prostate volume and r = 0.38, 0.40 and 0.33 respectively for TZ index)., Conclusions: There were very small differences between the correlations of total prostate volume, TZ volume and TZ index, and clinical and pressure-flow variables. In the assessment of the last two, the estimation of the total prostate volume by TRUS was a reasonable way to obtain the required information about prostate size and measuring TZ volume and calculating TZ index was of limited additional value. Symptoms and bladder outlet obstruction were mainly determined by other factors than the prostate and, specifically, TZ volume. As earlier studies have indicated that including pressure-flow data in the pre-operative evaluation and selection of patients for interventional therapies may improve the overall clinical results, we think that prostate volume, TZ volume or symptoms alone should not be used as the main indication for deciding on the appropriate invasive treatment options.