Search

Objectives: The microbubbles enhanced ultrasound contrast is a novel technique that informs us in real time of renal perfusion and microcirculation., Method: We reviewed the literature about its use in the study of renal masses in order to show their actual clinical performance in this condition., Result: This technique is useful in the differential diagnosis of pseudotumors, characterization and monitoring of small renal masses, the study of complex renal cysts and controlling the progression of renal masses that underwent ablative treatments. Like any diagnostic technique has some limitations on usage;its rapid contrast wash, being operator-dependent, require some experience and need special software to be correctly interpreted., Conclusions: The microbubbles enhanced ultrasound contrast is a useful and economic technique for the study and differential diagnosis of the renal masses.

Locally advanced renal cell carcinoma (RCC) with involvement to adjacent organs is uncommon and the prognosis is poor. Radical surgery remains the only effective treatment. We report the case of a woman with RCC and direct liver extension who was surgically treated. A literature review is made.

Objectives: The value of ultrasonography for the study of female urinary incontinence has been redefined over the last years., Methods: We review the literature about the value of ultrasound in the workup of females with urinary incontinence, mainly transperineal ultrasound for the female stress urinary incontinence (SUI)., Results: Many papers have been published over the last few years. Upper urinary tract ultrasound has not a place in the workup of genuine female SUI. Transperineal ultrasound allows to evaluate the mobility of the bladder neck and urethra, the thickness of the bladder wall, the funnel shape of the bladder neck, the presence of SUI or pelvic organ prolapse (POP), to visualize mesh implants, to help with biofeedback, and to evaluate changes after surgical treatment., Conclusions: Ultrasounds in general, and transperineal or translabial ultrasound in particular, are in the process of becoming the standard diagnostic method in urogynecology. Their wide availability, the standardization of parameters, the possibility of evaluating not only the bladder but also the levator ani muscle or pelvic organ prolapses (POP) contribute to this fact. It allows to obtain data in a non invasive way before and after therapy.

Objectives: To perform an update on the usefulness of ultrasound in the study of small size renal tumors and its current possibilities., Methods: We review the results of ultrasound in this pathology with the addition of the most recent technological advances such as a harmonic digital converters and power color Doppler. We analyze its contribution to the differential diagnosis of the cystic pathology, to the definition of solid masses, to the detection and characterization of small size masses, and to the definition of the vascular patterns of various tumors., Results: Ultrasonography offers a diagnostic safety of 98% in cystic masses, being able to detect them from 0.5 cm diameter in favourable conditions. The differential diagnosis of multiloculated masses, multivesicular hydatid cyst, multiloculated cystic nephroma, and multiloculated cystic carcinoma still poses great difficulty, the same way it happens with other radiological tests. For solid masses, the greater image resolution has lead to a progressive increase in the incidental detection of tumors and the percentage of patients candidates to conservative surgery due to the decrease in size. It is easy to differentiate between adenocarcinoma and angiomyolipoma, up to 85% of the cases, but the rest of the tumors do not have specific characteristics. For small size masses, smaller than 3 cm, ultrasound sensitivity is clearly inferior to CT scan. Power color Doppler helps to confirm the existence of solid masses and helps a better differential diagnosis with pseudo tumors., Conclusions: The modern ultrasound techniques provide a high cost-effectiveness both in detection and definition of the nature of small size renal masses.

Objectives: Although transrectal ultrasound-guided (TRUS) prostatic biopsy is the procedure of choice for the diagnosis of prostate cancer (PC), neither the ideal number of cores nor the number of repeated biopsies, nor the required diagnostic yield have been established. After our experience of ten years with TRUS biopsy we perform a review of the technique and its indications., Methods: PSA, ultrasound features, and pathologic data of 6000 patients undergoing modified sextant TRUS biopsy between 1994 to December 2002 were collected. 222 patients undergoing ten-core TRUS biopsy were included in an experimental group to study the role of the extended biopsy. The contribution of the extra cores to the diagnostic yield in the experimental group was studied to determine the effectiveness of the extended biopsy, using as a control group 552 patients undergoing sextant TRUS biopsy during 2002. Both groups were comparable for the study variables at the start of the study., Results: The incidence of PC in the first biopsy in the group of 6000 patients was 39.1% (2345/6000). Patients with PSA between 4 and 10 ng/ml have an incidence of PC greater than 50% among prostates smaller than 20 cc, diminishing down to 8.9% in those greater than 50 cc. The percentage of PC among patients with negative digital rectal examination (DRE), normal TRUS, and PSA below 4 ng/ml was 16.7%. The diagnostic yield for PSA density lower than 0.11 ng/ml/cc was lower than 8%. The free/total PSA ratio shows a 13.7% incidence of PC with values higher than 0.24. Multivariate logistic regression analysis showed that the only non-significant parameter was free/total PSA. Sixty (27.15%) patients of the extended TRUS biopsy group had PC. Only 2.25% of the 221 patients benefited from the augmented number of biopsies. There were no significant differences in the figures of prostate cancer between groups. Only PSA and volume where significant in the multivariate logistic regression analysis; number of samples, PSA density and age lacked of influence in the detection of PC., Conclusions: The sextant biopsy model obtaining cores from the lateral horns of the prostate continues to be the reference for TRUS biopsy, and the extended biopsy is not applicable to all patients from the beginning do to the small increase in the diagnostic yield. Isolated PSA may not be the unique reference to indicate TRUS biopsy, being volume, in our experience, a definitive factor for the adjustment of high risk levels.

Objectives: The aim of the study is to analyze the utility of ultrasound in the evaluation and treatment selection of patients with benign prostatic hyperplasia (BPH)., Methods: A total of 5000 patients older than 50 years and with prostatic symptoms were evaluated with abdominal ultrasound and in selected cases with transrectal ultrasound., Results: The first ultrasonographic sign of BPH is the increase of anteroposterior and longitudinal diameters. Prostatic volume is measured with a safety of 80%, post-void volume and indirect signs of bladder obstruction are also determined by ultrasound. Upper urinary tract pathological conditions can be also detected., Conclusions: Ultrasound associated with PSA and urinary flow are adequate to evaluate and select treatment in patients with BPH.

Objectives: To review the contribution of ultrasound to the differential diagnosis of scrotal pathology, both testicular and adnexal., Methods: We performed a bibliographic review on the topic, adding the experience of our Unit over the years; we classified the pathology in testicular and extratesticular, separating liquid and solid lesions, and a miscellaneous group of unclassifiable cases., Results: Currently, ultrasonography with high frequency equipment allows not only to differentiate between intra and extratesticular lesions, but also to identify specific lesions, the manage of which may include follow-up without need of unavoidable surgery., Conclusions: Ultrasonography is a painless simple test that may be repeated without inconvenience so that it is the first test to be indicated for any problem of the scrotal content.

Objective: To review the incidence of PIN and Atypical Small Acinar Proliferation (ASAP) on first biopsy, the risk to find cancer on following biopsies and what is the importance given to this findings, analizing how frequently and how long after the initial finding this patients are rebiopsied., Method: We selected 6000 patients who underwent TRUS biopsy between 1994 and 2002. Patients with prior cancer diagnosis were not included. 861 of them underwent more than one biopsy, adding up to a total of 7127 biopsies. A descriptive study has been done including percentages and percentiles for qualitative variables, mean and median for continuous variables., Results: Incidence of cancer on the first biopsy was 39,1%. PIN and ASAP are stable or slightly increase from 2 and 2,1% respectively on the first biopsy to more than 6% on the fourth and fifth ones. Mean time between biopsies when ASAP or PIN are the initial findings is 180 +/- 221,6 and 264 +/- 213,8 days respectively. Just 42 and 40% of patients with prior PIN or ASAP diagnose are rebiopsied. On subsequent biopsies 45 and 40% of cancers were respectively found., Conclusions: Presence of PIN or ASAP implies a higher cancer risk on subsequent biopsies; in spite of that, less than half of them are biopsied again. Performing two more biopsies or an amplified biopsy can find most of the tumors associated.

Objectives: The number of biopsy samples for a proper prostate cancer diagnosis has not yet been established. We report our experience with the 10-sample extended biopsy., Methods: We collected the results of a group of 222 patients undergoing extended ultrasound guided prostate biopsy with 10 samples. In addition to the sextant biopsies 2 extra samples were obtained from the dorsal-apex area on each lobe. Results of this group were compared with a control group of 552 patients undergoing sextant biopsy in 2002 with the same inclusion in criteria., Results: 60 patients had cancer (27.15%). The extra samples gave the diagnosis in 5 out of 60 patients, 8.33% of the tumors and 2.25% of all patients. Control group showed cancer in 24.5%, not having the difference statistical significance. The incidence in prostates smaller than 20 cc was 69.2%, 11.6% in prostates bigger than 50 cc. 80% of the patients with prostate cancer only in the extra samples have a volume smaller than 35 cc. Multivariate logistic regression study for the probability of prostate cancer only showed association with serum PSA and prostate volume but not with the number of samples., Conclusions: The extended biopsy is not indicated as an initial diagnostic technique, being reserved for specific cases such as repeated biopsies in patients with high risk pathology reports. Neither it is indicated in the bigger volume prostates.

Objectives: The growing interest on increasing the number of biopsy samples during ultrasound guided prostatic biopsies moved us to evaluate the tolerability and complications of the extensive biopsy with/without blockage of neurovascular bundles., Methods: A group of 222 patients underwent prostatic biopsy with the aim to obtain 10 cores on each. After evaluation of the first 50 cases performed without anesthesia, decision was taken to proceed with neurovascular blockage with 2% lidocaine, comparatively evaluating both groups for results on tolerability, complications and global adverse events., Results: The aimed number of cores could not be completed in 16% of the patients without anesthesia in comparison with 2.33% with anesthesia (p < 0.002); the biopsy was qualified as painful or very painful by 10.9% and 1.9% respectively (p < 0.0002). The results of the visual analogical scale for pain were 2.46 +/- 1.67 and 4.5 +/- 2.11 for the anesthesia/without anesthesia groups respectively, with mild-moderate vagal reactions in 28% of these latter in comparison with 7.7% in patients receiving lidocaine. Rectal bleeding was the most worrying complication, being moderate-severe in 4.7% of the patients, with 2% hospital admission., Conclusions: The increase in the number of ultrasound guided prostatic biopsy samples may be associated with a higher frequency of complications, mainly bleeding, and requires the application of local anesthesia due to worse tolerance. Neurovascular bundle blockage with lidocaine is very effective to diminish biopsy associated pain.

Objectives: The limitations of PSA to identify patients with prostate cancer prompted the definition of different parameters trying to increase specificity without reducing sensitivity. This paper studies the relationship of volume and presence of prostate cancer in sextant biopsies., Methods: We collected the results of prostate biopsies performed to 6000 patients between 1994 and 2002. 861 of them underwent more than one biopsy, adding up for a total of 7127 biopsies. Various predictive models to identify factors related to positive biopsy were constructed., Results: Mean prostate volume is 14.6 +/- 66.2 cc for the first biopsy, increasing in successive biopsies to 85.17 cc. A high incidence of prostate cancer was observed in small prostates, reaching 67.2% of those with normal size (< 20 cc) and diminishing with the increase of volume down to only 19.7% in those larger than 50 cc (p < 0.0001). In second biopsies of patients with PSA between 4 and 10 ng/ml and gland volume higher than 50 cc percentage of biopsies positive for cancer was below 10%. Multivariant logistic regression showed that PSA, volume and PSA density were related with positive biopsies, but not free/total PSA ratio., Conclusions: Standard PSA cutoffs are not adequate for a proper diagnosis of prostate cancer by ultrasound guided transrectal biopsy Volume (BPH) has a significant influence in PSA values and results of the biopsy, so that it should be taken into consideration when indicating biopsies.

Objectives: To analyze the results of transrectal ultrasound (TRUS) guided biopsy of the prostate in 6000 patients, and their relation to common-use clinical parameters., Methods: We collected PSA, digital rectal examination, TRUS characteristics, and pathology report in a data- base including 6000 patients who underwent sextant TRUS biopsy from 1994 to December 2002. 861 of them underwent more than one biopsy, accounting for a total of 7127 biopsies. Sextant biopsy with samples from the most lateral portions of the prostate was the standard procedure so that they included peripheral zone only. We analyze pathological results and their relation with clinical variables., Results: Total percentage of cancer in biopsy samples was 42.6%, with 39.1% in the first biopsy. Overall, repeated biopsies resulted in a 3.5% diagnostic yield increase. PIN or focal glandular atypia were detected in 2.0% and 2.1% of the cases respectively. The percentage of patients with Gleason score =<6 increased from 41.8% in the first biopsy to 70% in the third. Similarly, single core involvement increased from 21.% to 65%. Digital rectal examination and presence of hypoechogenic nodules specificity were 82.6 and 78.2% respectively. The incidence of prostate cancer with PSA between 4 and 10 ng/ml was 29.6%, 16.7% in those with PSA lower than 4 ng/ml., Conclusions: TRUS biopsy of the lateral prostatic areas offers a good diagnostic yield in comparison with most series of extensive biopsies. The sensitivity of TRUS has decreased but it maintains a high specificity which should not be forgotten when planning the TRUS strategy

Objectives: We review the results of 6000 patients with the clinical suspect of prostate cancer who underwent one or more prostate, biopsies, analyzing the role of PSA derived parameters in the probability of having prostate cancer in the TRUS biopsy., Methods: We selected 6000 patients who under- went TRUS biopsy between 1994 and 2002. 861 of them underwent more than one is biopsy, adding up to a total of 7127 biopsies. For the study of PSA derived indexes we established ranges based on the 10th percentile for the first biopsy for all patients and also for those with PSA between 4 and 10 ng/ml. Several predictive models were determined by logistic regression of the variables related with presence/no presence of cancer., Results: For first biopsies the ranges of PSAD established showed a diagnostic effectiveness below 8% with PSA densities lower than 0.11 ng/ml/cc. The free/total PSA ratio is less discriminant in the ranges obtained with a 13.7% incidence of prostate cancer for values above 0.24. In the case of second biopsies the group of patients with PSAD below 0.12 had only a 5.3% incidence, and only one patient with F/T PSA ratio higher than 0.24 had a prostate cancer (2.9%). All studied parameters but F/T PSA ratio showed statistical significance in the multivariant analysis., Conclusions: Although the establishment of a cut point for PSAD diminishes sensitivity, prostate biopsy habits should be modified assuming the loss of tumors in patients with low PSAD and increasing the number of biopsies in patients with total PSA values below 4 ng/ml with higher densities.

Objectives: To review the main images that can be observed by ultrasound, trying to highlight what decision to take after their finding: exploratory surgery, orchyectomy, or follow-up., Methods: We performed a bibliographic review about the topic and incorporated our personal experience with scrotal ultrasound. Given that there is an extensive variety of anomalies that can be observed we divide them in liquid and solid lesions, and these in intra or extratesticular, plus a group of lesions that do not qualify in the previous groups., Results: The development of high frequencies transducers (8-10 Mhz) and a greater experience today allows to diagnose not only testicular tumors but also a number of benign clinical entities, with enough specificity in some of them as to avoid surgery., Conclusions: Ultrasound is a simple test, painless, and can be repeated without trouble, so that it is the first test that should be ordered when managing any intra scrotal problem.

Objective: To report the case of a solitary renal metastasis secondary to hepatocellular carcinoma., Methods: We report the case of a 51 year old patient who on abdominal ultrasonography was revealed a left renal tumour and a hepatic mass incidentally. A TAC showed the left renal tumor measuring 17 cm in size, possible involvement of left renal vein and a tumour mass in the right lobe of the liver. A TAC guided fine needle punction aspiration biopsy demonstrated a malignant hepatic lesion compatible with hepatocarcinoma, and malignant renal cells compatible with renal or adrenal carcinoma. Left radical nephrectomy and right hepatectomy was performed., Results: Histopathologic study confirmed the diagnosis of moderately differentiated trabecular hepatocarcinoma with lymph node and left renal metastasis.

Objectives: We report six cases of adrenal cyst, a rare pathologic entity which poses diagnostic problems and therapeutic controversies., Methods: We report six cases of adrenal cysts in 4 female and 2 male patients ages 26 to 68 years. All cases underwent surgical treatment., Results: Pathologic studies showed that all were adrenal cysts without malignancy in any case., Conclusions: Adrenal cysts are a rare disease of which correct diagnosis is difficult so that many times patients undergo surgery without a proper preoperative diagnosis. There are controversies about the right management of adrenal cysts.

Transrectal prostate biopsy is the most accurate method for prostate cancer diagnosis. Although an antimicrobial prophylaxis is employed in most cases, infectious complications are among the most severe. We present a case of E. coli multirresistant meningitis after transrectal prostate biopsy despite quinolone prophylaxis.

Objectives: Ultrasound guided prostate biopsy is the most effective test for prostate cancer diagnosis, but its sensitivity is not higher than 80% so that biopsy repetition must be considered in patients with persistent diagnostic doubts after a previous negative one. However, the majority will be negative as it happened in the first biopsy and the percentage of normal biopsies increases successively. Various indexes based on PSA are proposed to determine which patients have a higher risk of cancer detection by biopsy. We evaluate the efficacy of PSA density (PSAD), free/total PSA ratio (F/T PSA) and PSA velocity (PSAV) to select patients with high PSA and previous negative biopsy., Methods: 546 patients who underwent more than one prostate biopsy were included in the study. 121 patients underwent 3 biopsies, 25 underwent 4 biopsies and 7 five biopsies, for a total of 1245 biopsies. Patients already diagnosed of prostate cancer who had received treatment, and postoperative urethrovesical anastomosis biopsies were excluded. Between 4 and 6 samples were obtained; transitional zone was included if previous biopsy was negative; sextant biopsy was repeated in high grade PIN, and 4 or 5 cores were taken from the affected side in cases with non conclusive glandular atypia. The relationship between PSAD, PSAV and F/T PSA and the diagnosis of cancer was evaluated, as well as its sensitivity, specificity, positive and negative predictive values., Results: 21.2% patients presented cancer on 2nd biopsy and 26% overall. Mean age was 68.3 years (51-84). Patients with cancer and negative biopsy showed significant differences in F/T PSA and PSAD, but not in PSAV. Sensitivities for PSAD higher than 0.15 ng/ml/ml, F/T PSA lower than 0.18 and PSAV higher than 0.75 ng/ml/year were 0.89, 0.9 and 0.49 respectively and specificities were 0.28, 0.2 and 0.4 respectively. ROC curve areas were calculated for these indexes being 0.63 for F/T PSA, and 0.47 for PSAV., Conclusions: Although their specificity is low, free to total PSA ratio and PSA density showed the highest sensitivity; PSAV is almost non valid to discriminate the result in the biopsy. Although we could slightly diminish the number of repeat biopsies loosing a few tumors, only the urologist can determine when biopsies should be repeated in patients with elevated PSA, taking into consideration all concurrent factors (Baseline status, age, risk-benefit ratio of new biopsies...).

Objective: To compare PSA density (PSAD) results based on prostate volume measurements obtained by either transrectal or abdominal ultrasound (US) in the diagnosis of prostate cancer., Methods: We prospectively selected 420 consecutive subjects whom at the time of a transrectal US (TRUS) guided biopsy or an abdominal US had the other US evaluation done within the previous 6 months and who did not undergo hormonal, surgical o radiotherapeutic therapy. For both abdominal and transrectal US PSAD (PSA/volume) were obtained from this data and compared, with volumes calculated using the formula: V = antero-posterior diameter2 x transverse diameter/2., Results: 140 patients had prostate cancer (33.8%). Using Student's t test mean differences were 0.27 cm for anteroposterior diameter, 0.39 cm for transverse diameter, 3.36 cc for volume and 0.014 for PSAD, being the differences significative in all cases (p < 0.001). When ROC curves were calculated for TRUS PSAD and abdominal PSAD areas obtained were 0.66 and 0.67 respectively. For a PSAD cut off point of 0.15, in patients with PSA values between 4-10 ng/ml Sensitivity was 0.77 for TRUS and 0.75 for abdominal US, and specificity was 0.40 and 0.49 respectively., Conclusions: Although statistically significative differences were found in all measurements between TRUS and abdominal US, most probably due to the high number of patients, these differences have little clinical relevance as the other results show. In our experience PSAD calculation by abdominal US has the same utility than by transrectal US and avoids its mayor inconvenience which is to perform TRUS.

Objective: Ultrasound-guided transrectal biopsy of the prostate is generally considered to be well-tolerated and with few complications. The results of a prospective study that evaluated patient and biopsy performer's perception of the foregoing aspects are presented., Methods: The records of 305 consecutive patients submitted to ultrasound-guided transrectal biopsy were analyzed. Aspects of the physical examination and biopsy performer's assessment of patient tolerance were recorded in 290 cases. 264 patients filled out a questionnaire on different aspects of the test. A telephone interview was carried out to obtain data on side-effects and complications of the biopsy procedure. Patient and biopsy performer's perception of tolerance and complications of ultrasound-guided transrectal biopsy were analyzed., Results: Biopsy could not be performed in 1% of the cases due to pain. Before biopsy 34.5% of the patients thought the procedure would be painful, while only 6.8% sustained this view after biopsy. Insertion of the transducer and punction were considered to be painful by 8% and 12.9% of the patients, respectively, and 2.9% considered anesthesia should be used for the procedure. Tolerance of biopsy punction remained unchanged throughout the procedure in 53.2% and became worse as the test proceeded in the remaining patients. Anxiety and increased anal tone were found to be the only factors that had an impact on tolerance. The complications were: fever > 38 degrees C (0.7%), rectal bleeding that required admission to the observation ward (1%), hematuria (51.1%), hemospermia (21.3%), difficulty in voiding (2.5%) and urinary retention (0.3%). Moderate vagal reactions were the most common immediate complications (2.4%)., Conclusions: Ultrasound-guided transrectal biopsy is generally well-tolerated and with few complications. Rectal bleeding is the complication that most frequently requires management and causes more anxiety to patients, but infection is the most severe.

Purpose: We reviewed the result of transrectal ultrasound (TRUS)-guided needle biopsies to find the re-biopsy criteria, emphasizing on the Focal Glandular Atypia (FGA) histological changes., Material and Method: 192 cases were selected, from a total of 1957 patients older than 50, re-biopsied because of high PSA levels and/or abnormal DRE, or because of the histological findings on initial biopsies (high grade PIN and/or FGA). The results are related to the serum PSA levels and DRE characteristics., Results: A 38.83% global positivity for cancer was obtained and 27.08% for re-biopsy. When the first biopsy was negative, the positivity of the re-biopsies was 19.37%; if it was negative for cancer but had high grade PIN and/or FGA changes, the positivity was 65.62%, being higher in FGA changes than in the PIN cases (68.00% vs. 57.14%). The abnormal DRE raised the positivity rate from 17.82% to, 35.75%., Conclusions: The positivity was especially related to abnormal DRE and/or PSA > or = 10 ng/ml. The tumor rate detected at second and third or successive biopsies was similar (19.28% vs 21.74%). The FGA changes (3.47% globally) had a cancer predictive value of 65.62%. We recommend re-biopsy in all patients with FGA changes.

We report the case of a 20-year old male with a right testicular tumor. Bilateral orchidectomy was practised considering the synchronous clinical, ultrasonographical and histological (intraoperative biopsy) findings of the left testis. The definitive pathological report showed a right embryonal carcinoma with wide intratubular germ cell neoplasia (IGCN) of the contralateral testis. IGCN (formerly carcinoma in situ) is present in about 5% of cases in the contralateral gonad of those patients with a testicular neoplasm. More than 50% will develop cancer in that testis. Clinical and physical examination findings are usually unspecific. The diagnosis of IGCN is based on biopsy, although ultrasonography could give some data too, as some authors report. We analyze the therapy options for IGCN: (orchidectomy, chemotherapy, radiotherapy, or "wait and see"). In our case, the first one was made. Chemotherapy was used due to existence of retroperitoneal lymph node metastases, with an excellent follow-up afterwards.

Objective: To compare the results of US-guided transrectal biopsy in 1,900 patients with the diagnostic yield of DRE, transrectal US, PSA, PSA density and free PSA/total PSA ratio and to describe our approach based on the results of the comparative study., Methods: Over the last two years 1,900 patients have undergone biopsy; 4 to 6 specimens were obtained randomly from both prostatic lobes and areas identified by transrectal US and/or DRE as being suspicious. All patients underwent transrectal US, DRE and determination of serum total PSA and PSA density. Free PSA and free PSA/total PSA ratio were determined in 128 patients with PSA 4-10 ng/ml. Seventy had a second biopsy, 8 a third and 3 had a fourth biopsy., Results: The overall diagnostic yield was 40%. Biopsy was positive in 27% of patients with PSA 4-10 ng/ml; of these, 64% showed a positive DRE, 21% showed a negative DRE and 13% were negative for both DRE and transrectal US. DRE was positive in 32% of patients with PSA greater than 10 ng/ml, 39% of those with PSA 10-20 ng/ml and 62% of those with PSA greater than 20 ng/ml; transrectal US was positive in 58% of patients with PSA 10-20 ng/ml and in 77% of those with PSA greater than 20 ng/ml. A high specificity was found for both DRE and transrectal US. In patients with PSA 4-10 ng/ml, PSA density at a cutoff of 0.15 ng/ml/cc showed a sensitivity of 81% and a specificity of 20%, respectively. A second biopsy was positive in 20% of patients with a persistently elevated PSA and the incidence of tumors theoretically of little importance was 13%., Conclusions: Patients aged less than 70 years whose general condition permit aggressive treatment of prostate cancer should undergo US-guided transrectal biopsy if PSA is greater than 4 ng/ml, regardless of DRE and ultrasound findings. PSA less than 20 ng/ml, PSA density and free PSA/total PSA ratio must be considered for a second biopsy. Sextant biopsy appears to have a good diagnostic accuracy and does not require taking additional specimens or including the transitional zone in the first biopsy. Before classifying a tumor as being of little importance on the basis of the biopsy findings, another biopsy must be performed.

Unlabelled: The most widespread opinion, and until recently the only option, is that every vesical transitional cancer invading the muscle is, regardless its extent, candidate for radical cystectomy and that in spite of nobody questioning the advantages of partial cystectomy., Material and Methods: 45 patients with vesical infiltrant cancer T2 or higher, followed between 9 and 258 months and managed with partial cystectomy, were analyzed. Only patients with no radiotherapy were included and only in one patient pre-operative chemotherapy was used., Results: In 8 patients no tumour was found in the specimen (pTO). Tumour grade was pTa in 2; pT1 in 11; pT2 in 5; pT3a in 4; pT3b in 11; and pX in 4 patients. Eight (8) patients had nodal involvement. Twenty-one (21) cases showed bladder relapse. In six (6), vesical infiltrant relapse was associated to metastasis. One case showed vesical relapse, pelvic mass and metastasis, and 4 only metastasis. Extravesical disease-free time and survival are better than in the group treated with radical cystectomy. But this is a highly selected group., Conclusions: With the same prospects of extravesical disease-free time and survival we offer: shorter, less risky surgery with low post-surgical morbidity and mortality and less hospitalization and proportion of late sequela. Better quality of life, with no skin stoma, incontinence or impotence Although the risk of vesical relapse persists, the procedures required to resolve vesical shunt or replacement complications are more aggressive than TUR sufficient to treat most relapses, and when recurrence is infiltrant radical cystectomy may be used as a rescue measure. This is so even now with the profusion of the so-called "mini-invasive" procedures. We believe that neither radio- and/or chemotherapy combinations contribute nothing to partial cystectomy alone. They may even be harmful and have significant side-effects. It is plain that POs are the result of total removal by TUR. Due to the little reliability when defining T, it is very hard to evaluate the contribution of adjuvant measures. Patients with no vesical tumour (pTOs) or pT1-pT2 tumours, and even up to pT3a, should not be included in protocols to evaluate the efficacy of combined cytostatic agents since their use is superfluous. Radiotherapy makes no contribution to this type of tumour in terms of local relapse and apparently has no effect on the metastasis.

Objective: To study the utility of PSA density and predicted PSA results in the diagnosis of prostatic cancer using gland volume., Methods: 500 patients suspected as having prostatic cancer underwent ultrasound-guided transrectal biopsy. Prostate volume and ultrasound characteristics, serum PSA density, predicted PSA and the difference between both were determined., Results: 44.8% of the patients showed evidence of cancer in the biopsy specimen. These patients had a significantly smaller prostate. The 0.1 and 0.15 PSA density cutoffs had a sensitivity of 96% and 94%, specificity of 10% and 20% and positive predictive value of 46% and 49%, respectively. The statistical values for PSA difference of 1 and 2 were 94% and 92%, 13% and 18%, 47% and 48%, respectively., Conclusion: PSA density and predicted PSA results could be useful to avoid biopsies in patients with PSA between 4 and 10 ng/ml and no malignant tumor of the prostate.

Objective: To analyze and compare the diagnostic yield of transrectal ultrasound versus digital rectal examination (DRE) and PSA., Methods: 500 patients with a suspicion of carcinoma of the prostate were evaluated by US-guided transrectal biopsy, PSA determination and DRE. The sensitivity, specificity and predictive values of these diagnostic methods, utilized alone or in combination, were analyzed., Results: 44.8% of the patients had evidence of cancer in the biopsy specimen. DRE disclosed an indurated prostate in 32% and 45% of the ultrasound scans were suspicious of malignancy (74.2% of those in whom a tumor was demonstrated and 20.4% of those with no tumor, p < 0.001). DRE, PSA > 4 ng/ml and transrectal ultrasound had a sensitivity rate of 52%, 93% and 74%, and a specificity of 85%, 10% and 79%, respectively. The highest sensitivity rate was obtained when biopsy was indicated by an indurated prostate on DRE or PSA > 4 ng/ml or a suspicious transrectal ultrasound scan (96%). The highest diagnostic accuracy, with a specificity of 96%, was obtained in patients with PSA > 10 ng/ml and positive DRE and transrectal ultrasound., Conclusion: The combined use of the different tests is fundamental to early diagnosis of prostatic cancer. In our experience, transrectal ultrasound was the method which independently obtained the best predictive values, offering a high sensitivity and specificity.

Objectives: To evaluate the influence of inflammatory foci of the prostate on the efficacy of PSA and transrectal ultrasound in the diagnosis of prostatic cancer., Methods: Ultrasound-guided transrectal biopsy was performed in 399 patients. The results of serum PSA, PSA density and ultrasound characteristics were compared with the pathological findings., Results: The mean prostatic volume was greater in the cases with BPH and chronic inflammatory foci than those with prostatic cancer (p < 0.001). Twenty percent of the patients showed suspicious areas vs 75.1% of the cancers (< 0.001); 66.7% of those with chronic inflammatory foci showed classifications vs 40.6% of the cancers (p < 0.001). The patients with chronic inflammatory foci had PSA values that fell in between those of the BPH and cancer groups (p < 0.05). PSA density also showed intermediate values, although they were not significantly different., Conclusions: The presence of chronic prostatic inflammatory foci can increase serum PSA levels. To date, it is not possible to identify this group of patients to avoid a biopsy.

Objectives: The widely accepted and, until recently, the only alternative in muscle-infiltrating transitional cell carcinoma of the bladder, whatever the extent of muscle infiltration, has been radical cystectomy, although the advantages of partial cystectomy has not been questioned., Methods: We reviewed the records of 34 patients with infiltrating carcinoma of the bladder stage T2 or higher and a follow-up ranging from 3 to 194 months, who underwent partial cystectomy. The patient received no radiotherapy and only one patient was treated with preoperative chemotherapy., Results: The surgical specimen was tumor free (pTO) in 7 patients, pT1 in 7 pts, pT2 in 4 pts, pT3 in 4, pT3b in 8 and Px in 4. Six patients showed lymph node involvement. Eleven patients had bladder recurrence; 3 had bladder recurrence and metastasis; 1 had bladder recurrence, a pelvic mass and metastasis and 2 had metastasis alone. We performed radical cystectomy in 2 cases; one for a prostatic cancer and the other for an upper urothelial tumor in a solitary kidney. Both bladders were tumor free. The extravesical disease free interval and survival were better that those of patients submitted to radical cystectomy, although this was a highly selected group., Conclusions: With the same possibilities relative to the extravesical disease free interval and survival, this approach requires a shorter operating time, carries less risk, low postoperative morbidity and mortality, requires less hospitalizations, and has less late sequelae. It affords a better quality of life, with no cutaneous stoma, incontinence or impotence. The risk of bladder recurrence persists, although the procedures required to resolve the complications of bladder diversion or substitution are more aggressive than TUR, which is sufficient for most of the recurrences, and if the recurrence is an infiltrating tumor, one can always recur to radical cystectomy. This is the current situation, even in the era of the so-called "minimally invasive techniques". We believe that in this group of patients combination preoperative radio- and chemotherapy would have contributed little to the partial cystectomy. In our series, it is evident that the pT0 is the result of complete resection by TUR. The differences in tumor definition make it very difficult to evaluate the benefits of the neoadjuvant measures. Patients with no bladder tumor (pT0) or pT1-pT2, and even pT3a tumors, should not be included in protocols for evaluating the efficacy of combination cystostatic therapy; many of them can be overtreated. Preoperative radiotherapy adds nothing with respect to local recurrence of this tumor type and it evidently has no effect on metastasis. We should not forget that the cytostatic agents currently utilized in combination therapy have severe side effects and are therefore only indicated in patients at higher risk of distant dissemination at diagnosis. Some studies, however, have indicated that the cytostatics may have some negative tumoral effect.

Objectives: Urological complications in renal transplantation occasionally denote the failure of a technique intended to provide the patient on hemodialysis a significant improvement of quality of life. Our experience in the management of these complicated cases which could not be resolved by conventional measures is described., Methods: Since the transplantation program began, our department has performed 530 renal transplants. There have been 40 fistulae (7.5%) and 23 stenoses (4.3%) of graft urinary tract. All the foregoing complications had been treated by endourological procedures (nephrostomy or ureteral stent) and/or simple ureteral reinsertion. There were 5 unresolved or recurrent fistulae (0.9%) and 2 stenoses (0.4%) that were repaired using the recipient's ipsilateral urinary tract (6 pyeloureterostomies and 1 pyelopyelostomy)., Results: Good results were achieved in all of the cases with adequate urinary tract function., Conclusions: Urological complications following renal transplantation can be successfully treated by surgical correction (pyeloureterostomy or pyelopyelostomy).

Objectives: The incidence of arterial hypertension post-renal transplantation has been reported to be 48.6%. The present study investigated the usefulness of echo Doppler in detecting renal artery stenosis and the effects of arterial pressure control and hypotensive agents on the vascular resistance of the renal graft., Methods: A total of 234 echo Doppler studies were done in 110 patients. The pulsatility index (PI), resistance index (RI), acceleration and mean velocity (MV), maximum systolic (SVMX) and minimum diastolic (DVMN) velocities of the external iliac, renal, segmental, interlobar and arcuate arteries were determined., Results: In the stenotic segment, an elevation of SVMX was observed, followed by turbulent flow in the post-stenotic segment in 73% of the cases with arterial stenosis. The hypertensive patients had a higher external iliac artery RI than the normotensives. The beta-blockers reduced the RI in large vessels (external iliac), the vasodilators in medium-sized extraparenchymal vessels (segmental) and the calcium antagonists changed the PI in the smaller caliber intraparenchymal vessels (interlobar and arcuate)., Conclusions: Evaluation by echo Doppler is the first diagnostic approach in patients suspected as having arterial stenosis of the renal graft. It permits evaluating blood flow changes from hypertension and hypotensive agents.

Objectives: The present study analyzed the place of ultrasound in the urological diagnostic protocols. Currently, most of the patients undergo some type of ultrasonographic evaluation at the outset or at some time during follow up. Our experience concerning the results, limitations and errors of this imaging technique are presented., Methods: We reviewed the indications for US in different pathologies and its use together with other diagnostic techniques. Simple, cost-efficient algorithms are described., Results: Its excellent performance permits making a correct diagnosis in many patients and remarkably simplifies evaluation in others. Its accuracy obviates the need for other explorations in certain pathologies., Conclusions: Ultrasound must be included in the urological armamentarium and should be considered as an extension of physical examination. Its accuracy and efficacy have been demonstrated. Furthermore, it is simple and easy to use, low-cost, and remarkably simplifies our diagnostic algorithms.

A total of 51 potential recipients of a renal transplant (RT) have been evaluated with an Eco-Doppler study of the posterior femoral, popliteal and posterior tibial corteries. Acceleration (AC), mean rate (MR), maximum systolic rate (MXSR) and minimal diastolic rate (MNDR), as well as pulsatility (PI) and resistance index (RI) were measured. Arterial high blood pressure (HBP), smoking, time in haemodialysis (HD) and cholesterol and triglycerides levels, were evaluated as vascular risk factors. RI and PI were maximal, and MXSR, MR and AC minimal at the popliteal artery level. Smoking (number of cigarettes/day) (R = 0.77), systolic blood pressure (BP) (R = 0.43), time of HBP evolution (R = 0.044), cholesterol level (R = 0.43) and time in HD (R = 0.35) correlate with Eco-Doppler parameters. Fifteen of these 51 patients underwent transplantation, and increased RR and PR with decreased MR and MXSR were seen post-RT in the ipsilateral popliteal and posterior tibial arteries. Eco-Doppler is a useful technique to evaluate the vascular risk of potential RT recipients.

An in vitro experimental study on stone fragmentation was conducted on 114 calculi analyzed by infrared spectrophotometry. Four energy sources were utilized: electrohydraulic, piezoelectric, ultrasound and pulsed laser. We analyzed stone susceptibility to fragmentation (particles < 3 mm), pulverization (particles < 1 mm) and stone fragility (amount of energy/mg of calculus fragmented into particles < 3 mm) for each type of energy source of each of the following 6 stone compositions: calcium oxalate monohydrate, calcium oxalate dihydrate, magnesium ammonium phosphate, phosphate carbonate, uric acid and phosphate oxalate. The calcium oxalate dihydrate calculi were the most susceptible to fragmentation and the infective calculi (magnesium ammonium phosphate and phosphate carbonate) were the most susceptible to pulverization. The piezoelectric energy showed the highest capacity for fragmentation and pulverization of calculi. Stone fragility depended on each stone type and the energy source utilized.

We studied a case of leiomyoma of the bladder floor in a woman with excretion urography, voiding cystourethrography, abdominal echography, computed tomography scan, and transvaginal echography. This last technique gave us the most accurate information about localization of the mass and its relation to adjacent organs. With these data we were able to indicate the most suitable surgical access. We think that this new application of the transvaginal echography should be included in the study of bladder flow masses in the female.