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The aim of the study was to investigate whether a novel simple measurement of pelvic anatomy, the pelvic anatomical index (PAI), which is obtained from simple physical examination, was predictive for potential difficulty and adverse outcome in radical prostatectomy.Available data from 73 consecutive radical prostatectomy patients were analyzed. The distances between umbilicus and cranial edge of the symphysis pubis (USPD) and between root of the penis and umbilicus (PUD) were measured. PAI was obtained using the formula (PUD/USPD) × body mass index (BMI). Indicators of surgical difficulty assessed were operation time (OT), dorsal vein bleeding (DVB), total blood loss (TBL), and surgical margin (SM) status. Patients with below-median values of the OT, DVB, TBL, and had negative SM were grouped as favorable surgery (n = 18).Median OT, DVB, and TBL were 215 (IQR: 187.5-240) min, 380 (IQR: 200-500) cc, and 1000 (IQR: 700-1300) cc, respectively. Both PAI and BMI were significantly correlated with TBL, DVB, and OT (p 0.05, for all). PAI and BMI significantly associated with favorable surgery (p = 0,006 and p = 0.048, respectively). However, only PAI was an independent predictor of favorable surgery in multivariable logistic regression analysis. A PAI 36 kg/mPAI significantly correlated with almost all surgical parameters and was a significant independent predictor of favorable surgery. PAI can enable the physician to select and discuss individualized treatment options for patients during preoperative planning.

We aimed to evaluate the prognostic value of the preoperative systemic inflammation response index (SIRI) to predict the outcomes after open radical cystectomy (RC).We conducted a retrospective analysis of the institutional cystectomy database and identified 241 consecutive RC patients. Patient demographics and oncologic outcomes were noted. We calculated the SIRI as previously described (NeutrophilxMonocytes/Lymphocytes), based on the blood-tests at the day before surgery and a minimum30-day later.Median follow-up time was 20 months (interquartile range 9-52). Two, 3 and 5 years recurrence free (RFS) and overall survival (OS) rates were 60.6%, 57.1%, 48.9%, and 54.7%, 47.0%, 37.2%, respectively. Patients with preoperative SIRI1.91 had significantly higher recurrence rates (P0.001) and lower OS (P0.001). For internal validation, we evaluated postoperative SIRI1.91 (repeatability testing), and again found significantly higher recurrence rates (P0.001) and lower OS (P = 0.004). Persistently high SIRI increased the recurrence and death risk 5.79 and 2.87 fold, respectively. SIRI was also a significant independent predictive factor for RFS and OS in the multivariable cox regression analyses (P0.05). SIRI improved the discriminative ability of the models 1.5% to 4.2% and this was quite higher than other inflammatory markers (NLR, MLR, PLR, SII) in all models.Patients with SIRI1.91 had significantly higher recurrence and lower OS rates. The cut-off value is validated internally. SIRI is an independent predictive factor for RFS and OS. The contribution of SIRI in the cox models is higher than other inflammatory markers.

We aimed to assess an “Immunological Profile (IP)” including CD8+ and FoxP3+ T lymphocytes for renal cell carcinoma (RCC) to evaluate its effects on tumor pathological characteristics, disease progression, and survival. Adjacent normal and intratumoral specimens from 42 patients who had undergone radical nephrectomy for RCC were analyzed for counts of CD8+ and FoxP3+ T lymphocytes by immunohistochemistry. Tissue from both sites were evaluated and scored separately according to low (0) or high (1) expression of CD8 and FoxP3. A total score (min: 0, max: 4) was assigned to each patient. Thereafter, patients were divided into two groups for clinicopathologic and survival stratification based on score (IPWeak 0–2; and IPStrong 3–4). Survival curves were constructed using the Kaplan–Meier method, and a multivariable Cox regression model was used for overall survival (OS) and progression-free survival (PFS). The mean follow-up was 54.73 ± 21.34 months. Poor RCC characteristics including pT3–T4, tumor necrosis, lymphovascular invasion, lymph node involvement, and larger tumor size were significantly more common in the IPWeak patients compared to IPStrong (p

Purpose: The implantable bladder cancer (BC) models allow the researchers to perform rapid and useful experiments for BC. We investigated the implantation success of BC cells obtained from Wistar rats (grown in vitro), into bladders of syngeneic Wistar rats, which are commonly used in the laboratories. Methods: The Nara Bladder Tumor No.2 (NBT-II) BC cells induced with 4-hydroxybutylnitrosamine were grown with passages in Kocaeli University Center for Stem-Cell and Gene-Therapies. After urothelial denudation, 2x106 NBT-II cells were then implanted into bladders of 24 female Wistar rats (aged 7-8 weeks). The rats were randomly divided into four experimental groups; three instillation groups (8 per group) and one sham-operated control group consisting of 6 rats. First, second and third instillation groups were sacrificed at days 7, 14, and 21, respectively, and, bladders were histopathologically evaluated for BC according to WHO / International Society of Urological Pathology. Results: All tumors were pT1 (including 1 rat that prematurely died at 5th day), except one rat that died prematurely at 8th day had pT2 tumor. Implantation rates were 28.58% (2/7) in the first group, and 42.85% (3/7) in the second, for a cumulative rate of 35.71% (5/14) in these two-groups (until 14th day). Interestingly, there was no tumor in the third group, but there was an inflammatory granulation tissue. Conclusion: Seeding NBT-II cells into bladders of Wistar rats was described, successfully tested and demonstrated in this study. This implantable BC model of Wistar rats may be improved to increase the success rate of BC cell implantation in new studies with higher number of animals.

Introduction Residual stone fragments remain a challenging topic for urologists following retrograde intrarenal surgery (RIRS). This study investigates the effectiveness of second-look flexible ureterorenoscopy (URS) to achieve a true stone-free status and decrease stone-related events. Material and Method A total of 176 consecutive patients treated with RIRS for kidney stones were included in the study. Patients were divided into two groups, group 1 receiving the standard of care (n=51) and group 2 receiving second-look flexible URS (n=125). In all cases, one or more calyceal stones of 1 to 4 mm were extracted with a basket at the time of stent removal. Unless earlier intervention was necessary, patients were followed up every six months to determine if they had experienced SREs. Results The mean follow-up time for the whole group was 21±11.1 months. The mean number of stones in group 1 and group 2 was 1.25±0.11 and 1.56±0.19, respectively. Postoperative stone-free rate after RIRS for group 1 and group 2 were 37.25% (n=19/51) and 40.8% (n=51/125), respectively. The SFR improved to 93.6% (n=117/125) in group 2. Multivariable analysis showed that type of intervention, stone size, and body mass index were independent prognostic factors for SREs. When group 2 was taken as a reference, the odds ratio for SREs was 8.48 (95% CI: 2.95–24.42) in group 1. Conclusion This study found that second-look flexible URS increased the SFRs and diminished the number of SREs. We propose performing second-look flexible URS following RIRS in the presence or suspicion of RSFs to provide better treatment results, less radiation exposure, and greater patient satisfaction. Key Words Retrograde Intrarenal Surgery, Flexible Ureteroscopy, Stone-free Rate, Residual stone Fragments, Stone-Related Event, Second-look Flexible Ureteroscopy.

Objective The incidence of prostate adenocarcinoma (PCa) is increased with the use of prostate-specific antigen (PSA). In the current study, we aimed to investigate the impact of 5- alpha- reductase inhibitors (5-ARI) on pathological progression in patients followed by active surveillance (AS). Material and methods Records of 69 patients with localized prostate cancer under AS (PSA ≤15 ng/mL, PSAD ≤0.20, ≤cT2c, Gleason sum ≤3+3, the number of cancer positive cores ≤3) were evaluated retrospectively. Patients were followed-up with quarterly PSA testing and semiannual digital rectal examination during the first 2 years, and semiannual PSA testing thereafter. Repeat biopsies were done annually and whenever indicated by clinical findings. Pathological progression was defined as increasing Gleason grade, number of cancer-positive cores, and/or increasing percentage of cancer in any core. Results Patients using (29/69: 42%) and not using (40/69: 58%) 5-ARI were followed for a median of 39 (IQR: 23-45) and 23.5 (IQR: 17-37.5) months, respectively. Pathological progression was observed in 32% (22/69) of the patients at a median of 25 (IQR: 18-39) months. Pathological progression was observed in 34.5% (10/29) and 30% (12/40) of the patients using and not using 5-ARI, respectively (Log-rank p=0.4151). Definitive treatment was done in 31% (9/29) and 47.5% (19/40) of the patients using and not using 5-ARI, respectively. Patients who did not use 5-ARI received definitive treatment earlier than 5-ARI users (Log-rank p=0.0342). On multivariate analysis, more than 2 cancer-positive cores (HR: 11.62) and age (HR: 0.94) were independently associated with pathological progression (p

Although non-muscle invasive bladder cancer (NMIBC) is widely seen in men, most laboratory studies of new intravesical therapies to prevent NMIBC have been conducted on female animals. In addition, ozone (O3) has been shown to be a beneficial agent as an intravesical application in the treatment of various disorders. In the current study, we evaluated the immunohistopathological and oxidative-antioxidative effects of intravesical O3 treatment on n-methyl-n-nitrosourea (MNU)-induced NMIBC. Male Wistar-Albino rats (n=51) were divided into four groups: sham (n=6), O3 only (n=15), MNU only (n=15), and MNU+O3 (n=15). The MNU-only and MNU+O3 groups received MNU, and the O3-only group received saline every other week for 10 weeks. The MNU-only group received 1 ml saline in place of O3 treatment, whereas the O3-only and MNU+O3 groups were treated with 1 ml 25 µg/ml O3 between the 7th and 12th weeks. Rat bladders were collected in the 15th week for immunohistopathology and oxidant-antioxidant quantitation. Oxidant-antioxidant parameters were determined by ELISA. Although all surviving rats in the MNU-only group had preneoplastic (4/11, 36.4%) or neoplastic changes (7/11, 63.6%), a completely normal urothelium was observed in 2 rats (2/12, 16.7%) in the MNU+O3-group (P=0.478). More high-grade lesions were observed in the MNU-only group (4/11, 36.4%) than in the MNU+O3 group (1/12, 8.3%) (P=0.120). All oxidant-antioxidant parameters significantly increased (P

Recent studies have shown that Aurora-A expression is associated with bladder cancer initiation and progression. In this study, the effects of intravesical Aurora-A inhibitor Alisertib (ALS) and bacillus Calmette–Guerin (BCG) were compared on bladder carcinogenesis. Two mg N-Methyl-N-nitrosourea was administered intravesically to forty of Wistar-albino rats every other week for 8 weeks. At week 10, rats were divided into four groups (10/group): No-treatment (vehicle), ALS-alone, BCG-alone, and ALS + BCG. The intravesical treatment of ALS, BCG, and ALS plus BCG was performed once a week for 6 weeks. At week 16, bladders were collected for immunohistopathological and Western blot analysis. The cell cycle regulators p53, p21, Aurora-A, phosphorylated Aurora-A (p-Aurora-A), and apoptotic marker cleavage of poly [ADP-ribose] polymerase (c-PARP) were determined by Western blot. Histopathologically relatively healthy urothelium was observed in ALS + BCG group (87.5%) compared to the ALS-alone (50%) and the BCG-alone (50%) groups. The lowest expression of p21 and p53 was detected in the BCG-alone, while the highest level of expression was evident in no-treatment group. The ALS treatment alone caused a slight decrease in Aurora-A while there was a dramatic decrease in p-Aurora-A in comparison to no-treatment group. In overall combined treatment with ALS + BCG significantly increased c-PARP compared to all mono-treatments, and decreased all cell cycle parameters compared to no-treatment group. Although intravesical ALS treatment has similar antiproliferative effects like BCG, ALS + BCG combined treatment led to a best histopathologic and apoptotic response. Consequently, BCG combined with Aurora-A inhibition may provide a new intravesical treatment modality in the prevention of bladder carcinogenesis.

Introduction: To evaluate the pathological outcomes of Turkish men meeting the criteria for Active Surveillance (AS), who elected to undergo immediate radical prostatectomy (RP). Material and Methods: Retrospective analysis including 1,212 patients with clinically localized prostate cancer (PCa) who met the eligibility criteria for AS. The primary outcomes were pathological upstaging and pathological upgrading. Results: Nine hundred ninety-one patients were eligible for analysis after the central review of the submitted data. The mean prostate-specific antigen (PSA) level was 6.89 (0.51–15) ng/mL and the mean biopsy core number was 12 (8–47). The mean tumor positive core on final biopsy pathology was 1.95 (1–6) (16.6% [2.1–33.3%]). Overall, 30.6% of the men experienced a Gleason sum (GS) upgrade and 13.2% had pathological upstaging. For GS upgrade, the percentage of tumor-positive cores and free-to-total-PSA ratio were significant both in univariate analysis and multivariate logistic regression analysis. Variables predicting pathological upstaging were percentage of tumor-positive cores and PSA density, which were significant in univariate analysis. However, only PSA density was significant in multivariate logistic regression. Although biochemical recurrence-free survival was longer in patients without GS upgrade, it was not statistically significant between patients with and without any GS upgrade (mean 133.7 vs. 148.2 months, p = 0.243). A similar observation was made for patients with or without pathological upstaging (mean 117.1 vs. 148.3 months, p = 0.190). Conclusions: Upgrading and upstaging at RP are quite common among Turkish men with clinically low-risk PCa, who are candidates for AS, and a great majority of them experienced long-term PSA control.

Background We aimed to evaluate the relationship between perineural invasion (PNI) and bone metastasis in prostate cancer (PCa). Methods We retrospectively reviewed the data of 633 PCas who had whole-body bone scan (WBBS) between 2008 and 2014. We recorded the age, clinical T-stage, total PSA (tPSA) prior to biopsy, Gleason sum (GS), and PNI in transrectal ultrasound guided biopsy (TRUS-Bx) and digital rectal examination findings. Bone metastases were assessed with WBBS and magnetic resonance image if WBBS was suspicious. We divided the patients into two groups according to NCCN criteria: (Group 1) bone scan not indicated, (Group 2) bone scan indicated. Results There were 262 patients in Group 1 and 371 in 2. There is not significant relationship between PNI and bone metastasis in Group 1. However, there is very limited number of metastatic patients (n = 12) in this group. There is a strong relationship between PNI and bone metastasis in Group 2 (P = 0.001). Sensitivity, specificity and positive predictive value of PNI for bone metastasis were 72.4%, 81.7%, and 77.7%, respectively. In this group, tPSA, GS, positive DRE, and PNI were significant covariates for prediction of bone metastasis in univariate and multivariate analysis (except age). The most powerful predictor was PNI, and it increased the risk of bone metastasis 11-fold. Conclusions PNI in the TRUS-Bx specimens is the most powerful predictive histopathological feature for bone metastasis, by increasing the risk of bone metastasis 11-fold in NCCN bone scan indicated patients (Group 2). Prostate 75:1783–1789, 2015. © 2015 Wiley Periodicals, Inc.

The aim of this study was to evaluate the predictive role of percentage of free prostate-specific antigen (%fPSA) cut-points in prostate cancer (PCa) detection in patients with total PSA (tPSA) levels between 2.5 ng/mL and 10.0 ng/mL. In total, 1321 consecutive initial transrectal ultrasound (TRUS)-guided 12-core biopsies performed between 2005 and 2011 were evaluated retrospectively. Benign pathologies, high-grade prostatic intraepithelial neoplasia, and atypical small acinary proliferations were categorized as noncancerous (benign), and prostate adenocarcinomas were categorized as cancerous (malignant). The patients were categorized according to: Catalona's published %fPSA categories ( 25%); digital rectal examination (DRE) results [benign (negative) or suspicious of malignancy (positive)]. There was a significant relationship between the %fPSA cut-points and detection of PCa in DRE-negative patients. The presence of a 10% cut-point increased the probability of PCa threefold. The %fPSA was significantly more related to PCa than the tPSA value in receiver operating characteristic (ROC) curve analyses (p = 0.001). Based on our findings, a lower %fPSA, especially

Prostate biopsy guidelines recommend that a prostate biopsy not containing glandular prostate tissue should be reported as inadequate. In the literature, there is a lack of any study that addresses the relationship between the length of biopsy cores and the absence of glandular prostate tissue. In this study, we aimed to determine whether a relationship exists between these parameters.We retrospectively evaluated 1,712 consecutive initial transrectal 12-core prostate biopsies. Individual cores were histologically categorized as glandular (benign or malignant) and non-glandular (rectal mucosa, periprostatic adipose tissue, prostatic or periprostatic fibromuscular tissue). Total number of evaluable cores ≤9, highly fragmented, incorrectly numbered or dried biopsies, patients with 5-α reductase inhibitory treatment were excluded.We analyzed remaining 1,584 patients; 41.7 % had adenocarcinoma. A total of 19,144 cores were sampled. Non-glandular cores were found significantly shorter than glandular cores (p0.0001). The percentages of non-glandular cores were significantly higher at the base, apex and lateral biopsy sites (p0.0001). We found a 6-mm cutoff value for accurate prediction of glandular sampling with 80.2 % sensitivity and 78.7 % specificity. The risk of non-glandular sampling increased 15-fold in cores ≤6 mm (OR 14.91, 95% CI 13.20-16.83, p0.0001).Non-glandular sampling was directly associated with shorter core lengths. They were found significantly higher at the base, apex and lateral localizations. We found a 6-mm cutoff value for the prediction of non-glandular samples before the histologic evaluation. Below this value, the risk of non-glandular sampling increased 15-fold. We suggest it for prompt additional sampling during biopsy procedure.

To evaluate the effect of pre-operative alprazolam medication on anxiety and pain in flexible cystoscopy for bladder cancer follow-up.A total of 86 male patients who had flexible cystoscopy for bladder cancer follow-up at 6th and 9th months were included in the study. A visual analog scale (VAS) pain score and the State-Trait Anxiety Inventory (STAI) were used. The 6th (VAS-1)and 9th (VAS-2) month pain scores and 6th month STAI score (STAI-1) and, 9th month STAI score before (STAI-2a) and after alprazolam (0.5 mg) intake (STAI-2b) were compared.The mean age was 66.49±12.45 years. Patients were grouped by age≤65 (Group-1) and age≥66 (Group-2). Mean VAS score for VAS-1 and VAS-2 were 2.66±0.96 and 2.44±1.05, respectively (p=0.007). The mean VAS-1 and VAS-2 scores in Group 1 were 3.0±1.05 and 2.73±1.18, respectively (p=0.009). The mean VAS-1 and VAS-2 scores in Group 2 were 2.36±0.77 and 2.17±0.86 respectively (p=0.031). The differences between mean anxiety scores were all statistically significant. All STAI (1, 2a, and 2b) and VAS (1 and 2) scores in Group-1 were statistically significantly higher than Group-2. Increasing STAI score is associated with a statistically significant increase in the VAS scores in the 0.50 and 0.75 quantiles (p=0.021 and p=0.039, respectively).Using alprazolam before flexible cystoscopy reduces both anxiety (STAI-1 vs STAI-2b) and pain (VAS-1 vs VAS-2). Previous cystoscopy experience reduces anxiety (STAI-2a vs. STAI-2b). Elderly patients have less anxiety and pain scores than younger patients in flexible cystoscopy.

Intravesical Bacillus Calmette-Guerin (BCG) is the best treatment modality for progression of non-muscle invasive bladder cancer. We aimed to monitor changes at the proteome level to identify putative protein biomarkers associated with the response of urothelial precancerous lesions to intravesical BCG treatment. The rats were divided into three groups (n = 10/group): control, non-treated, and BCG-treated groups. The non-treated and BCG-treated groups received N-methyl-N-nitrosourea intravesically. BCG Tice-strain was instilled into bladder in BCG-treated group. At the endpoint of experiment, all surviving rat bladders were collected and equally divided into two portions vertically from dome to neck. Half of each bladder was assessed immunohistopathologically and the other half was used for 2D-based comparative proteomic analysis. Differentially expressed proteins were validated by Western blot analysis. Precancerous lesions of bladder cancer were more common in non-treated group (77.8%) than in BCG-treated group (50%) and the control group (0%). Greater than twofold changes occurred in the expression of a number of proteins. Among them, Rab-GDIβ, aldehyde dehydrogenase 2 (ALDH2) and 14-3-3 zeta/delta were important since they were previously reported to be associated with cancer and their expression levels were found to be lower in BCG-treated group in comparison to the non-treated group. ALDH2 and 14-3-3 zeta/delta were also found to be highly expressed in the non-treated group compared to the control group. The down-regulation of these proteins and Rab-GDIβ was achieved with BCG; this result indicates that they may be used as putative biomarkers for monitoring changes in bladder carcinogenesis in response to BCG immunotherapy.

Only a few papers in the literature aimed to evaluate biopsy core lengths. Additionally, studies evaluated the core length with different approaches. We aimed to determine whether prostate cancer (PCa) detection is affected from core lengths according to three different approaches in a large standard cohort and compare our cut-off values with the published cut-offs.We retrospectively analyzed 1,523 initial consecutive transrectal ultrasound-guided 12-core prostate biopsies. Biopsies were evaluated with respect to total core length (total length of each patients' core) average core length (total core length divided by total number of cores in each patient), and mean core length (mean length of all cores pooled), and compared our cut-off values with the published cut-offs. The prostate volumes were categorized into four groups (30, 30-59.99, 60-119.99, ≥120 cmPCa was found in 41.5% patients. There was no difference between benign and malignant mean core lengths of the pooled cores (p0.05). Total core length and average core length were not significantly associated with PCa in multivariate logistic regression analyses (p0.05). The core lengths (mean, average and total core lengths) increased (p0.001) and PCa rates decreased (p0.001) steadily with increasing prostate volume categories. PCa percentages decreased in all categories above the utilized cut-offs for mean (p0.05), average (p0.05), and total core lengths (p0.05).There was no difference between mean core lengths of benign and malignant cores. Total core length and average core length were not significantly associated with PCa. Contrary to the cut-offs used for mean and average core lengths in the published studies, PCa rates decrease as these core lengths increase. Larger studies are necessary for the determination and acceptance of accurate cut-offs.

Introduction Human papillomavirus (HPV) is one of the most common sexually transmitted infections and is the cause of several different diseases in men and women. Although little is known about HPV infection in men, they are also in the risk group of HPV infection and play an important role in transmitting the virus to women. Aim To define the efficacy of the HPV vaccine through cross-immunization and its role in clearance of HPV infection, and to assess infection-associated factors in men. Methods This prospective randomized clinical study enrolled 171 evaluable men with genital warts between June 2009 and October 2013. After the initial treatment intervention, 91 patients were randomly assigned to receive HPV vaccine in three doses. Eighty patients were in the control (unvaccinated) group. One hundred-eleven men were single and 60 men were married. Patients who had previous treatment for pre-existing warts and medical disorders that needed chronic treatment or immunosuppression were not included in the randomization. Also 29 men with follow-up less than 12 months and incomplete vaccination were not included. Main Outcome Measures The patients were assessed regarding age, condom use, marital status, number of visible genital warts, and smoking status. Post-treatment follow-up was monthly up to 12th month. Results Mean age was 34±7.6. One hundred fifteen patients were smokers. For the recurrence of warts, age, smoking, vaccination status were insignificant and marital status was significant in the univariable analysis; only marital status preserved significance (HR: 2.0 CI:1.29–3.12 P =0.002) in the multivariable analysis including vaccination status, marital status, and smoking. Conclusion Among the investigated factors vaccination status was not but marital status significantly influenced wart recurrence. Married men had more recurrences in our population. Larger multicenter randomized clinical trials are lacking and seriously required to investigate the therapeutic effect of current quadrivalent HPV vaccine in genital warts. Coskuner ER, Ozkan TA, Karakose A, Dillioglugil O, and Cevik I. Impact of the quadrivalent HPV vaccine on disease recurrence in men exposed to HPV infection: A randomized study. J Sex Med 2014;11:2785–2791.

We aimed to assess the relationship between prostate volume (PV) and high grade prostate carcinoma (HGPCa) in patients with benign and suspicious digital rectal examination (DRE) in our prostate biopsy cohort.Between 2009-2012, 759 consecutive initial transrectal systematic 12 cores prostate biopsies were included. PVs were calculated with transrectal ultrasound. Only prostate adenocarcinomas (PCa) were included into the study. For standardization, patients with missing data, and who have been exposed to any form of hormonal or radiation therapy were excluded. Patients were categorized with DRE (negative or positive) and Gleason sum [7: low grade PCa(LGPCa), ≥7: HGPCa].Median PV was significantly lower in patients with HGPCa. There was a significantly increased risk of HGPCa with PV according to all groups in univariate logistic regression (LR). The significant relationship continued in multivariate LR with PSA and age. From the ROC curve analyses, again a significantly statistical concordance was found between the detection of HGPCa and PV (AUC:0.63, p0.001), as well as between HGPCa and tPSA (AUC:0.73, p0.001). tPSA and PV were also significantly concordant with HGPCa both in DRE negative and positive patients.There is a significant relationship between HGPCa and decreasing PV. The continued significant relationship both in DRE negative and positive patients reinforces this relation.

Our objective was to examine blood and tissue levels of nitric oxide (NO) and malondialdehyde (MDA), and their correlations with well-known prognostic indicators [total prostate-specific antigen (tPSA), %free/total PSA (%f/t PSA), pathological stage (pT), and Gleason sum] in patients who had radical retropubic prostatectomy (RRP) for localized prostate cancer (PCa) without metastasis.Preoperatively 31 patients' bloods were obtained for determination of NO, MDA, fPSA, tPSA, and %f/tPSA ratios. Tissues were obtained from RRP specimens for determination of NO and MDA. Gleason sum was assigned for each patient, and pT was determined according to 2002 TNM staging system. pTs were as follows: 10 pT2a, 7 pT2b, 8 pT2c, 4 pT3a, and 2 pT3b. Gleason sum of the PCa in the RRP specimens was as follows: 5 in 1, 6 in 14, 7 in 14, and 9 in 2 patients.There were strong correlations between blood and tissue levels of NO (r=0.83, p0.001) and MDA (r=0.63, p0.001), between serum NO and plasma MDA (r=0.88, p0.001), and finally between tissue NO and tissue MDA (r=0.83, p0.001). There was also a significant (p0.05) relationship between all well-known prognostic indicators of PCa (tPSA, %f/tPSA, Gleason sum, and pT) and blood and tissue NO and MDA levels, with single exception of correlation between tissue MDA and Gleason sum (p=0.073).Clinically appropriate correlations shown in this study indicates that NO and MDA may be used for prognostic assessment of localized PCa, especially if supported with other well-designed studies including higher number of patients through multi-institutional collaboration.

We determined the frequency and distribution of metastases to pelvic lymph nodes in a contemporary American radical prostatectomy series.In 642 consecutive patients with clinically localized prostate cancer treated by a single surgeon between 2002 and 2009 pelvic lymph nodes were removed and submitted to the pathologist in separate packets (external iliac, obturator and hypogastric). We assessed the total number of nodes and the number with metastases in each packet.Complete pathological information was available for 427 patients, who had a median of 16 lymph nodes removed. Of the patients 35 (8.2%) had lymph node metastases, including 1.7% with low, 8.6% with intermediate and 23.9% with high risk cancer. Of those with nodal metastases 24 (69%) had positive lymph nodes in only 1 of the 3 areas, including the external iliac in 4 (11%), the obturator in 9 (26%) and the hypogastric in 11 (31%). Only 37% of the patients had positive nodes only in the external iliac area above the obturator nerve while 60% and 49% had at least 1 positive node in the obturator and the hypogastric area, respectively. Of the patients 80% had only 1 (49%) or 2 (31%) positive nodes.In contemporary American patients with clinically localized prostate cancer lymph node metastases were found more often and frequently exclusively in the obturator and hypogastric areas than in the external iliac area. Pelvic lymph node dissection limited to the external iliac area above the obturator nerve would identify and remove lymph node metastases in only a third of the patients with positive nodes found at full pelvic lymph node dissection.

Two percent of the bladder non-muscle-invasive (NMI) transitional cell carcinomas (TCC) are associated with upper urinary tract (UUT) TCC. We evaluated the role of nuclear matrix protein-22 (NMP-22) (BladderChek) test in the diagnosis of lower urinary tract and UUT-TCC.From March 2009 to June 2011, 122 patients with bladder NMI-TCC underwent 205 control cystoscopy. A total of 95 (78 men and 17 women, mean age 60.7 years, range, 27-88) patients who were followed regularly with NMP-22 test and with follow-up cystoscopies (145 episodes; min. 1-max. 5) were included in this study. For routine monitoring of the UUT, IVU or CT urography was used once a year for high grades (HG), and once in every other year for low grades (LG). The sensitivity and specificity of NMP-22 were evaluated by ROC curves, and sensitivity, specificity, and positive and negative predictive values were calculated. Chi-square test was used for the differences between the subgroups.Cystoscopy and NMP-22 results of the patients included in the study revealed the sensitivity (44.4%) of the test was very low and the specificity (98.4%) was quite high (p0.001). Among the 10 cystoscopies where NMP-22 was negative, but cystoscopy was positive for tumor, 8 had LG and 2 had HG TCC. NMP-22 was never positive in low-grade tumors, in other words, all of the NMP-22-positive 8 tumors were high grade. On the other hand, in 20% (2/10) of the cases, NMP-22 can be negative although the tumor was high grade. Two (2.1%) HG UUT-TCC were detected in 95 patients. These 2 patients were within the 125 cystoscopies (75 patients) where both NMP-22 and cystoscopy were negative for tumor.Nuclear matrix protein-22 cannot detect LG TCC. However, it detects overwhelming majority of HG TCC. For this reason, positive NMP-22 test largely indicates HG TCC. NMP-22 is also not reliable in UUT-TCC, even in HG tumors.

In the great majority of the cases, transrectal ultrasound guided prostate biopsy (TRUS-Bx) is the definitive step in the diagnosis of prostate cancer (CaP). Although this procedure is well tolerated by most patients, it can result in considerable discomfort that can effectively be overcome with local injection anesthesia. In this study, we evaluated the effect of the size (i.e., circumference) of the transrectal probe on pain during TRUS-Bx.One hundred and seventy eligible patients who had elevated total prostate specific antigen (tPSA) and/or abnormal digital rectal examination (DRE) were included in this study. Patients (pts.) were divided into three TRUS-Bx groups; Group I: 60 pts. underwent TRUS-Bx with newer B-K Type 8808 probe (circumference 58 mm) under injectable periprostatic anesthesia, Group II: 60 pts. underwent TRUS-Bx with B-K Type 8551 probe (circumference 74 mm) under injectable periprostatic anesthesia, and Group III: 50 pts. underwent TRUS-Bx with B-K Type 8551 probe (circumference 74 mm) without local anesthesia. Periprostatic injection anesthesia was performed with 10 cc, 1% lidocaine (5 cc on each side) 10 min before TRUS-Bx. Pain was assessed using a 10-point modified visual analog scale (VAS) 15 min after the biopsy procedure.Three groups were homogeneous with respect to age and tPSA, and no statistically significant difference was observed in terms of mean biopsy duration between the 3 groups. Most of the patients experienced no pain to slight pain in Groups I and II, but 66% of the patients had more than moderate pain (VAS ≥ 5) in Group III with mean VAS score statistically higher than the other two groups (Group I vs. III, P = 0.0001; Group II vs. III, P = 0.0001). Mean VAS score was not statistically different between Group I and II (P = 0.126). No statistically significant difference in VAS pain perception was observed between different age categories within the Group I, II, and III.In the absence of injectable local anesthesia, larger probe (74 mm) results in much higher VAS pain perception than same size and smaller (58 mm) probe used under injectable local anesthesia. However, under injectable local anesthesia, the size (circumference) of the transrectal probe (58 mm vs. 74 mm) does not result in any different pain perception during TRUS-Bx.

Ureteral stent placement after ureteroscopic lithotripsy has some advantages and disadvantages. In this randomized study, the necessity of ureteral stent placement after uncomplicated ureteroscopy for impacted ureteral stones was assessed.Between 2005 and 2007, 60 evaluable patients were equally randomized to groups with and without stents. Patients underwent ureteroscopic pneumatic lithotripsy for ureteral stones. The operation was completed with or without stent placement according to the randomization order. Excretory urography was performed 3 months after the procedure. All stents were cystoscopically removed at the third postoperative week. Sociodemographic and clinical variables (age, sex, stone location, stone size, operative time, hospital stay, narcotic and nonnarcotic analgesic use), and postoperative complications (fever, pain delaying discharge, emergency department visit, urinary retention, stent-related irritative symptoms) were evaluated.Mean stone size was not significantly different in both groups. Mean operative time was significantly longer in the stent group: 30.5 +/- 9.6 vs 43.7 +/- 11.6 minutes. On the operation day and until postoperative day (POD) 5, narcotic (P = 0.004) and nonnarcotic analgesic (P = not significant) use was more frequent in the no-stent group. At POD 5 and later, although narcotic and nonnarcotic analgesic use were frequently necessary in the stent group, both were almost unnecessary in the no-stent patients. Stent-related irritative symptoms were overwhelmingly higher (10% vs 93%) in the stent group. Discharge was delayed (23% vs 10%) and unplanned emergency department visits (20% vs 10%) were exercised almost two times more commonly in the no-stent group. Stone-free rates were identical (n = 29/30; 97%) in both groups.Routine placement of a ureteral stent is not mandatory in patients without complications after ureteroscopic lithotripsy for impacted ureteral stones. Stent placement can be argued and agreed with the patients preoperatively in the light of the data presented above.

Retained surgical gauze is a rare but known problem in patients who have medical history of surgery. Suspicion and evaluation of this rare condition is sometimes very difficult for the clinician because retained surgical sponges can be totally asymptomatic or can hide themselves perfectly in the plain abdominal films. For this reason clinican should excersize high rate of suspicion, should not solely depend upon plain films and should consider more sophisticated examinations like ultrasonography (US) or computerized tomography for the appropriate management of these retained sponges. We present here a very unusual and late presentation of surgically retained gauze which gave a false appearance of a kidney with decreased functional activitity in the excretory urography (EU) 32 years after nephrectomy.

We aimed to evaluate the relationship between perineural invasion (PNI) and bone metastasis in prostate cancer (PCa).We retrospectively reviewed the data of 633 PCas who had whole-body bone scan (WBBS) between 2008 and 2014. We recorded the age, clinical T-stage, total PSA (tPSA) prior to biopsy, Gleason sum (GS), and PNI in transrectal ultrasound guided biopsy (TRUS-Bx) and digital rectal examination findings. Bone metastases were assessed with WBBS and magnetic resonance image if WBBS was suspicious. We divided the patients into two groups according to NCCN criteria: (Group 1) bone scan not indicated, (Group 2) bone scan indicated.There were 262 patients in Group 1 and 371 in 2. There is not significant relationship between PNI and bone metastasis in Group 1. However, there is very limited number of metastatic patients (n = 12) in this group. There is a strong relationship between PNI and bone metastasis in Group 2 (P = 0.001). Sensitivity, specificity and positive predictive value of PNI for bone metastasis were 72.4%, 81.7%, and 77.7%, respectively. In this group, tPSA, GS, positive DRE, and PNI were significant covariates for prediction of bone metastasis in univariate and multivariate analysis (except age). The most powerful predictor was PNI, and it increased the risk of bone metastasis 11-fold.PNI in the TRUS-Bx specimens is the most powerful predictive histopathological feature for bone metastasis, by increasing the risk of bone metastasis 11-fold in NCCN bone scan indicated patients (Group 2).

Objectives To evaluate, in a prospective study, the benefit of adding local periapical prostatic anesthesia to routine periprostatic infiltration to the prostate-seminal vesicle junction in a randomized fashion. Transrectal ultrasound-guided biopsy is the reference standard in the diagnosis of prostate cancer. Although well tolerated by most patients, it can be associated with discomfort. Methods A total of 120 consecutive evaluable patients with an elevated total prostate-specific antigen (tPSA) level, increased tPSA velocity, and/or abnormal digital rectal examination findings were enrolled. The patients were randomized into two groups. Group 1 received periprostatic infiltration of 6 mL 1% lidocaine. Group 2 received periprostatic and apical infiltration: 4 mL 1% lidocaine at the prostate-seminal vesicle junction and 2-mL infiltration at the prostatic apex 15 minutes before transrectal ultrasound-guided biopsy. Pain was assessed using a 10-point modified visual analog scale. Results The mean patient age was 63.7 ± 1.2 years and 64.2 ± 1.1 years, the mean tPSA level was 12.1 ± 1.5 ng/mL and 13.6 ± 2.7 ng/mL, the mean biopsy duration was 6.2 ± 2.5 minutes and 6.1 ± 2.2 minutes, and the mean visual analog scale pain score was 1.26 ± 0.1 and 1.23 ± 0.1 for groups 1 and 2, respectively. No statistically significant difference was observed with respect to age, tPSA level, mean biopsy duration, or pain score between the two groups. Conclusions Periprostatic lidocaine infiltration provides local anesthesia that results in improved visual analog scale pain scores. Additional apical infiltration did not improve patient discomfort further. However, comparative evidence has indicated that increasing the time elapsed between the anesthetic infiltration and the biopsy procedure may further improve pain control.

Objective: Cisplatin (DDP, cis-diamminedichloroplatinium II) is one of the most potent chemotherapeutic antitumor drugs, but is able to generate reactive oxygen species (ROS) and it also inhibits the activity of antioxidant enzymes in renal tissue. In the present study, we investigated the preventive effect of 100, 200 and 400 mg/kg b.w. doses of vitamin E (VE), and 25, 50, and 100 mg/kg b.w. doses of vitamin A (VA) combination on malondialdehyde (MDA), nitric oxide (NO), and glutathione (GSH) levels and superoxide dismutase (SOD) activity in cisplatin-induced toxicity in rat kidneys. Our literature survey indicated a lack of any experimental study showing the beneficial effect of VA on cisplatin-induced MDA, NO, GSH and SOD changes. For this reason, we hoped that this study would provide a unique contribution in that respect. Materials and Methods: 59 Wistar rats (11 to replace prematurely lost animals) were used. 48 evaluable rats were divided into 8 groups (n = 6 in each group): control group, DDP alone (5 mg/kg b.w.) group, 3 VE combination treatment groups of VE100+DDP, VE200+DDP, and VE400+DDP, and 3 VA combination treatment groups of VA25+DDP, VA50+DDP, and VA100+DDP. Kidney MDA, GSH, NO levels and SOD activities were determined for the assessment of oxidant-antioxidant balance. Results: While in the DDP group the tissue levels of MDA and NO were found to be significantly higher than in the control group, GSH levels and SOD activities were significantly lower. MDA and NO levels were found to be significantly lower and GSH levels and SOD activities significantly higher in the VE200+DDP and VE400+ DDP groups when compared with the DDP alone group. MDA and NO levels were found to be significantly lower in the VA50+DDP and VA100+DDP groups when compared with the DDP alone group. However, identical comparisons with the DDP alone group showed significantly higher GSH levels and SOD activities in the VA25+DDP, VA50+DDP, and VA100+DDP groups. Among the VE100+ DDP, VE200+DDP, and VE400+DDP groups, and VA25+ DDP, VA50+DDP, and VA100+DDP groups, MDA and NO levels decreased and GSH levels and SOD activities increased steadily and significantly as the doses of VE and VA increased. Conclusion: These vitamins would be effective in protecting against cisplatin-induced tissue damage in rat kidneys. It is possible that the toxic effect of cisplatin is somehow minimized by a compensatory mechanism involving VE and VA via induction of antioxidant enzyme activities following intraperitoneal injection of DDP.

Bipolar plasma kinetic (BP) transurethral resection of prostate (TURP) has been proved to be a safe and effective treatment for benign prostatic enlargement (BPE). However, the role of bipolar TURP on large prostates over 100 g compared with open suprapubic prostatectomy (SP) in elderly patients (65 years) has not ever been studied before.A retrospective analysis of patients' medical records between 2007 and 2012 was performed. A total of 102 patients who underwent SP (n = 44) or BP-TURP [Gyrus Plasma Kinetic™ (Gyrus ACMI, USA)] (n = 58) for obstructive lower urinary tract symptoms due to BPE were included in this retrospective study. Inclusion criteria were age ≥65 years, prostate volume ≥100 g, International Prostate Symptom Score (IPSS) ≥18, and peak urinary flow rate (PFR) ≤15 ml/s. Exclusion criteria were urethral stricture, known history of neurogenic bladder due to neural disorders, previous prostate and/or urethral surgery, bladder stone, bladder cancer, and known prostate cancer. Operation time, hospitalization, and catheter removal times were noted. Patients were re-evaluated at postoperative 3rd and 12th months. Evaluated parameters were IPSS, quality of life (QoL), simplified International Index of Erectile Function-5 (IIEF-5), PFR, post-voiding residual urinary volume (PVR). Statistical significance was set at 0.05 and all tests were two-tailed.Preoperative IPSS, PVR, IIEF-5, QoL, and prostate volume were not statistically significantly different between two groups except for PFR. Mean follow-up for BP-TURP and SP groups were 15.0 ± 5.8 (R: 11-38), 22.1 ± 11.2 (R: 11-59) months, respectively (p0.001). When compared with SP, mean catheter removal time (p0.001) and median hospitalization time (p0.001) were significantly shorter in BP-TURP group. However, mean operative time was significantly (p0.001) longer than SP group and also median resected material weight was significantly lower in the BP-TURP group (p0.001). IPSS, QoL, PFR, PVR, and IIEF-5 scores at postoperative 3rd and 12th month were not significantly different between the two groups (p0.05). Thirty-three patients had perioperative complications according to the modified Clavien-Dindo system. Thirteen patients (22.4 %) in BP-TURP group and 20 patients (45.4 %) in SP group had complications. In 12th month follow-up visit, four patients presented with urethral stricture, three patients (5.1 %) were in BP-TURP group, and one patient (2.3 %) in SP group (p = 0.455). All strictures were treated with internal urethrotomy.BP-TURP is a safe and highly effective treatment modality for BPE in the elderly patients with prostate glands over 100 g. Clinical efficacy and postoperative 12th month's results were similar to SP. Larger studies with longer follow-up are needed in order to confirm our findings.

To evaluate exclusion of prostate cancer (PCa) by using empiric antibiotic treatment for patients with total prostate specific antigen (PSA) between 4-10 ng/ml. A hundred asymptomatic men with a PSA between 4-10 ng/ml and normal digital rectal examination (DRE) were enrolled in this randomized prospective study. The treatment group (n=50) was given 400 mg of ofloxacin daily for 4 weeks, whereas the control group (n=50) was followed without any treatment. At the end of the four weeks, repeat PSA were measured and all patients underwent transrectal ultrasound (TRUS) guided biopsy, regardless of the repeat PSA levels. Totally 22 patients (22%) had prostate cancer (9 in treatment group and 13 in control group). A significant PSA decrease was observed in the treatment group at repeat PSA measurements (p=0.001). The PSA drop was also significantly more in patients without PCa than with PCa (p=0.028). In patients whose repeat PSA after antibiotic treatment decreased below 4 ng/ml, 2 times as many patients (16.6%) had PCa in the control group when compared with the treatment group (8.3%). On the other hand, in patients whose repeat PSA remained above 4 ng/ml, PCa was detected in 27.3% of the patients in the control group and 21% in the treatment group. Empirical antibiotic treatment in asymptomatic patients with a PSA level 4-10 ng/ml and a normal DRE may be used to select prostate biopsy candidates. Studies with higher number of patients may result in more powerful associations with narrower confidence intervals for increased confidence.

INTRODUCTION AND OBJECTIVES: Human papillomavirus (HPV) is one of the most common sexually transmitted infections. In 2009, FDA recommended HPV vaccine for the prevention of external genital lesions caused by HPV 6, 11, 16, or 18. There are conflicting results regarding cross protection from naturally occurring HPV infection. According to recent studies HPV vaccination can induce neutralizing antibodies across HPV species. Our purpose was to define the importance of immunization and its role in clearance of HPV infection and to assess infection-associated factors in men. METHODS: This prospective randomized trial enrolled 200 men with genital warts (GW), between June, 2009 and October, 2013. GW were diagnosed solely with their clinical features and their reaction to the aceto-white. Pathologic examination was performed in suspicious cases. Initial treatment was local excision with electrocautery or electrocautery alone in all patients. After the initial intervention, 200 patients were randomly assigned to receive a HPV vaccine in three doses (0, 2, 6 mos). Hundred patients were in the control (unvaccinated) group. All men were circumcised and reported only female sexual partners. Thirtynine men were excluded due to pre-existing medical disorders that needed chronic treatment or caused immunosuppression, follow-up (F/ U) less than 12 months and incomplete vaccination. Finally, 171 consecutive patients were included in study. There were 91 men in the vaccinated group and 80 men in the control group. One hundred-eleven were single and 60 men were married. The patients were assessed regarding age, marital status (MS), number of GW, physical examination and smoking status. Post-treatment F/U was monthly up to 6 months and one more at the 12th mo. GW recurrences were analyzed with Cox proportional hazards model. RESULTS: Mean age was 34 7.6. One hundred-fifteen (67.25%) patients were smokers. For the recurrence of GW, age, smoking, vaccination status (VS) were insignificant and MS was significant (p

We report a case of urinary bladder carcinosarcoma with simultaneous testicular seminoma. A 60-year-old male presented with painless gross hematuria and a left testicular mass. The bladder tumor was deeply infiltrating muscular tissue and had histologic features of both carcinoma and sarcoma. Testicular tumor was diagnosed as classical seminoma. Radical cystectomy, pelvic and left-modified retroperitoneal lymphadenectomy were performed. The lymph nodes did not show metastasis. At the 26 months follow-up, the patient is free of disease.

This study was performed to assess the relationship between the level and extent of prostatic capsular invasion (PCI) by cancer and the clinical and pathological features and prognosis of early-stage prostate cancer. We conducted a retrospective analysis of the clinical (age, stage, grade, prostate specific antigen [PSA] level) and pathological (tumor volume, stage, grade, surgical margins) features of 688 patients treated with radical prostatectomy to determine the pathological features and probability of recurrence associated with various levels of PCI. Radical prostatectomy specimens were serially sectioned and examined by whole-mount technique. Progression-free probabilities (PFP) after radical prostatectomy were determined by Kaplan-Meier and Cox proportional hazards regression analysis. Progression was defined as a rising serum PSAor = 0.4 ng/mL or clinical evidence of recurrent cancer. Increasing clinical stage, Gleason grade in the biopsy specimen, and pretreatment serum PSA levels were each associated with increasing levels of PCI (P.001). In the radical prostatectomy specimen, increasing levels of PCI were significantly associated with increasing tumor volume (P.001), Gleason grade (P.0001), seminal vesicle involvement (SVI, P.001) and lymph node metastases (+LN, P.001). None of 138 patients without capsular invasion had SVI or lymph node metastases (+LN), and all remained free of progression, even though some had large volume (up to 6.26 cm3) or poorly differentiated (Gleason sum up to 8) cancers. Invasion into the capsule (n = 271) was occasionally associated with SVI (6%) or +LN (3%) and a significantly (log-rank test) lower PFP of 87% at 5 years. Focal and extensive extraprostatic extension (EPE) were associated with progressively increased risk of SVI and +LN and lower PFP (73% and 42%, respectively). In a multivariate analysis, the level of PCI was an independent prognostic factor (P.001). There is a strong association between the level of invasion of cancer into or through the prostatic capsule and the volume, grade, pathological stage, and rate of recurrence after radical prostatectomy. Prostate cancer does not appear to metastasize in the absence of invasion into the capsule regardless of the volume or grade of the intracapsular tumor. Subclassification of patients according to the levels of PCI provides valuable prognostic information.

Objectives. Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction. Methods. Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average length of stay and average hospital charges among the three groups. We also compare average length of stay among physician volume groups: high volume physicians performed at least 12 operations per year; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications were assessed in the clinical pathway and nonpathway groups. Results. Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively). Conclusions. Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.

PURPOSE Some investigators have analyzed the rate of growth of prostate cancer that has recurred after definitive radiotherapy or radical prostatectomy using serum prostate-specific antigen (PSA) doubling times (DT). We examined all PSA values in recurrent patients to determine the pattern and rate of increase in PSA after radiation therapy and radical prostatectomy. PATIENTS AND METHODS Charts of 96 recurrent radical prostatectomy patients (mean age, 62.8 years; range, 47 to 76) and 42 recurrent radiation therapy patients (mean age, 67.2 years; range, 52 to 83) were reviewed. All available PSA values between the date of operation/radiation treatment and last follow-up evaluation or the initiation of second-line therapy are included. Rate of PSA DT was not assumed to be constant over time; it was instead allowed to vary. We use a piecewise linear random-coefficients model in time for log (PSA), which allowed different mean models for both treatments. RESULTS The PSA DT in the first year after radiation therapy was--1.17 years, which reflects the continuous decline in PSA in the average patients during the first year after radiotherapy despite eventual biochemical progression. In contrast, the PSA DT in the radical prostatectomy group was 0.66 in the first year. In year 2, after radiation therapy, the PSA DT was lengthy at 1.82 years, significantly longer (P = .0025) than in the radical prostatectomy group (0.76 years). After year 2, there were no significant differences between the two groups (P > .05). CONCLUSION A piecewise linear random-coefficients model enables interval analysis of PSA DT. While the PSA DT after radiation therapy and radical prostatectomy are different in the first 2 years, the rate of increase in PSA appears to be similar in the two groups after year 2, which suggests the rate of growth of cancers that recur after radiation therapy and radical prostatectomy is similar.

Purpose: With recognition of the efficacy of surgical therapy for prostate cancer, there has been a marked increase in the number of radical prostatectomies performed, and substantial changes in surgical technique and perioperative management have decreased the morbidity of this procedure. We assessed the rate of perioperative complications with time and the risk factors for these complications, particularly age, operative time and co-morbidity.Materials and Methods: A detailed review of all medical records of a consecutive series of 472 patients treated with radical retropubic prostatectomy by 1 surgeon between 1990 and 1994 was performed to document any complication within 30 days postoperatively. American Society of Anesthesiologists (ASA) physical status classification recorded by the staff anesthesiologist was used as a standard index of co-morbidity.Results: Major complications were identified in 46 patients (9.8%), minor complications in 101 (21.4%) and none in 341 (72.2%). There were 2 dea...

Several common misconceptions have fueled the debate over the early detection and treatment of prostate cancer. While prostate cancer is often described as a common cancer that older men die with rather than of, the reality is that the incidence, mortality, and mean age and stage at diagnosis of prostate cancer are very similar to those of breast cancer, which is rarely the subject of similar concerns. Many studies have confirmed that given enough time, all clinically detected prostate cancers will inexorably progress locally and eventually metastasize to regional lymph nodes as well as to distant sites. The relatively slow doubling time compared to that of other cancers and the wide spectrum of biologic activity of prostate cancer have made retrospective studies reporting the long-term survival of conservatively treated patients highly suspect due to selection bias and inadequate follow-up. While it is accepted that a large number of men harbor clinically insignificant cancers in their prostate glands, these estimates have been based on careful pathologic step-sectioning studies of prostates obtained either at autopsy or after cystoprostatectomy for bladder cancer. Several studies have now demonstrated that currently available diagnostic modalities for detecting prostate cancer, DRE, PSA, and TRUS, are not able to detect a significant proportion of small, clinically unimportant cancers. Rather, studies have shown that while the traditional DRE has been largely unsuccessful in detecting prostate cancers at a sufficiently early stage for effective treatment with either radical prostatectomy or radiation therapy, a combination of the DRE and PSA followed by TRUS and ultrasound-guided biopsy in those with abnormal results can detect an increased proportion of clinically significant prostate cancers while they are still confined to the prostate gland and thus more likely to be eradicated by treatment. Several randomized trials are now under way in this country and in Europe that may settle many of these issues over the next decade. However, currently available data suggest that prostate cancer screening holds the promise of decreasing the considerable morbidity and mortality caused by this disease.

As longevity has improved and mortality from cardiovascular and other diseases has declined, the risk of death from prostate cancer has increased steadily. Though slow growing, prostate cancer is not a benign disease. Nearly 10% of men in Western countries will be diagnosed with prostate cancer sometime during their life and 3% will die of the disease. The prospects for long-term control of prostate cancer diminish rapidly once the cancer has spread beyond the immediate periprostatic tissue. The 5-year survival rate for men with metastases is less than 30% and almost all will eventually die of their disease. A simple blood test, prostate-specific antigen (PSA), is available. This test, when used in conjunction with ultrasound-guided systematic needle biopsy of the prostate, will detect potentially lethal prostate cancers earlier than digital rectal examination (DRE). Definitive treatment, especially with radical prostatectomy, can eradicate the tumor in 90% of patients if the cancer is still confined to the prostate pathologically, regardless of the tumor grade. Randomized, prospective clinical trials are now underway to demonstrate conclusively whether screening or early definitive therapy will substantially reduce the mortality rate from this disease. Until the results of these trials are available, we recommend that healthy men over age 50, who have a life expectancy of 10 years or longer, have an annual PSA and DRE to detect prostate cancer while it is still curable.

In an attempt to enhance the success of prostate-specific antigen (PSA) in the diagnosis and staging of prostate carcinoma (PCa) the concept of PSA density (PSAD) has been introduced by Benson et al. Likewise a study to investigate the role of PSAD in 53 patients with PCa and 47 patients with benign prostatic hyperplasia (BPH) has been done. PSADs seemed to increase directly proportional to the grade in PCa and differed significantly between patient groups with BPH and localized+metastatic PCa, BPH and localized PCa, and localized PCa and metastatic PCa. Although 0.6 level for PSAD seemed to be a rational cut-off level in our study, this issue needs to be studied in multiple centers involving an increased number of patients for resolution.