Risk factors for incidental prostate cancer-who should not undergo vaporization of the prostate for benign prostate hyperplasia?

Concomitant Prostate Needle Biopsy and Laser Vaporization of the Prostate Could Be a Risk of Postoperative Hemoglobin Decline, a Retrospective Study

Purpose

Contact laser vaporization of the prostate (CVP) for benign prostatic hyperplasia is a widely accepted and safe procedure for elderly patients because of its lower bleeding risks. However, CVP lacks a postoperative pathological examination for prostate cancer. Concomitant prostate biopsy and CVP may complement this disadvantage; however, the risk of bleeding associated with this procedure remains unclear. This study aimed to evaluate the safety of a concomitant prostate biopsy and CVP.

Patients and Methods

This retrospective study included 106 men who had undergone CVP in Nerima General Hospital. Prostate biopsies and CVP were performed simultaneously on 16 patients. We defined the "hemorrhage group" by a >5% decrease in hemoglobin the day after surgery. Preoperative and operative indices were evaluated based on the association with the hemorrhage group.

Results

Participants in the concomitant biopsy group were older (p = 0.001), had larger prostates (p = 0.014), a lower rate of prostate biopsy history (p = 0.046), longer postoperative urinary catheter duration (p = 0.024), and a higher rate of decline in hemoglobin levels the day after surgery (p = 0.023). Patients in the hemorrhage group (n = 20, 18.9%) showed a significantly higher rate of concomitant biopsy and CVP (p = 0.006). Multivariate analysis showed that concomitant prostate biopsy (p = 0.009, odds ratio = 4.61) was the sole statistically significant predictive factor for hemorrhage.

Conclusion

Concomitant prostate biopsy and CVP of the prostate may increase the risk of bleeding.

Current Trends in Incidence and Management of T1a and T1b Prostate Cancer

Prostate cancer (PCa) identified incidentally (iPCa) after surgical treatment for symptomatic benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is considered low risk by the most current guidelines. Management protocols for iPCa are conservative and are identical to other prostate cancers classified as having favorable prognoses. The objectives of this paper are to discuss the incidence of iPCa stratified by BPH procedure, to highlight predictors of cancer progression, and to propose potential modifications to mainstream guidelines for the optimal management of iPCa. The correlation between the rate of iPCa detection and the method of BPH surgery is not clearly defined. Old age, small prostate volume, and high pre-operative prostate-specific antigen (PSA) are associated with an increased likelihood of detecting iPCa. PSA and tumor grade are strong predictors of cancer progression and can be used along with magnetic resonance imaging (MRI) and potential confirmatory biopsies to determine disease management. In instances that iPCa requires treatment, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy all have oncologic benefits but may be associated with increased risk after the BPH surgery. It is advised that patients with low to favorable intermediate-risk prostate cancer undergo post-operative PSA measurement and prostate MRI imaging before electing to choose between observation, surveillance without confirmatory biopsy, immediate confirmatory biopsy, or active treatment. Subdividing the binary T1a/b cancer staging into more categories with ranging percentages of malignant tissue would be a helpful first step in tailoring the management of iPCa.

The significance of the extent of tissue embedding for the detection of incidental prostate carcinoma on transurethral prostate resection material: the more, the better?

The aim of this study is to investigate the incidental prostate cancer (iPCa) detection rates of different embedding methods in a large, contemporary cohort of patients with bladder outlet obstruction (BOO) treated with transurethral surgery. We relied on an institutional tertiary-care database to identify BOO patients who underwent either transurethral loop resection or laser (Holmium:yttrium–aluminium garnet) enucleation of the prostate (HoLEP) between 01/2012 and 12/2019. Embedding methods differed with regard to the extent of the additional prostate tissue submitted following the first ten cassettes of primary embedding (cohort A: one [additional] cassette/10 g residual tissue vs. cohort B: complete embedding of the residual tissue). Detection rates of iPCa among the different embedding methods were compared. Subsequently, subgroup analyses by embedding protocol were repeated in HoLEP-treated patients only. In the overall cohort, the iPCa detection rate was 11% (46/420). In cohort A (n = 299), tissue embedding resulted in a median of 8 cassettes/patient (range 1–38) vs. a median of 15 (range 2–74) in cohort B (n = 121) (p < .001). The iPCa detection rate was 8% (23/299) and 19% (23/121) in cohort A vs. cohort B, respectively (p < .001). Virtual reduction of the number of tissue cassettes to ten cassettes resulted in a iPCa detection rate of 96% in both cohorts, missing one stage T1a/ISUP grade 1 carcinoma. Increasing the number of cassettes by two and eight cassettes, respectively, resulted in a detection rate of 100% in both cohorts without revealing high-grade carcinomas. Subgroup analyses in HoLEP patients confirmed these findings, demonstrated by a 100 vs. 96% iPCa detection rate following examination of the first ten cassettes, missing one case of T1a/ISUP 1. Examination of 8 additional cassettes resulted in a 100% detection rate. The extent of embedding of material obtained from transurethral prostate resection correlates with the iPCa detection rate. However, the submission of 10 cassettes appears to be a reasonable threshold to reduce resource utilization while maintaining secure cancer detection.

Dynamics of urinary and respiratory shedding of Severe acute respiratory syndrome virus 2 (SARS-CoV-2) RNA excludes urine as a relevant source of viral transmission

PURPOSE

To investigate the expression of the receptor protein ACE-2 alongside the urinary tract, urinary shedding and urinary stability of SARS-CoV-2 RNA.

METHODS

Immunohistochemical staining was performed on tissue from urological surgery of 10 patients. Further, patients treated for coronavirus disease (COVID-19) at specialized care-units of a university hospital were assessed for detection of SARS-CoV-2 RNA in urinary samples via PCR, disease severity (WHO score), inflammatory response of patients. Finally, the stability of SARS-CoV-2 RNA in urine was analyzed.

RESULTS

High ACE-2 expression (3/3) was observed in the tubules of the kidney and prostate glands, moderate expression in urothelial cells of the bladder (0-2/3) and no expression in kidney glomeruli, muscularis of the bladder and stroma of the prostate (0/3). SARS-CoV-2 RNA was detected in 5/199 urine samples from 64 patients. Viral RNA was detected in the first urinary sample of sequential samples. Viral RNA load from other specimen as nasopharyngeal swabs (NPS) or endotracheal aspirates revealed higher levels than from urine. Detection of SARS-CoV-2 RNA in urine was not associated with impaired WHO score (median 5, range 3-8 vs median 4, range 1-8, p = 0.314), peak white blood cell count (median 24.1 × 1000/ml, range 5.19-48.1 versus median 11.9 × 1000/ml, range 2.9-60.3, p = 0.307), peak CRP (median 20.7 mg/dl, 4.2-40.2 versus median 11.9 mg/dl, range 0.1-51.9, p = 0.316) or peak IL-6 levels (median: 1442 ng/ml, range 26.7-3918 versus median 140 ng/ml, range 3.0-11,041, p = 0.099). SARS-CoV-2 RNA was stable under different storage conditions and after freeze-thaw cycles.

CONCLUSIONS

SARS-CoV-2 RNA in the urine of COVID-19 patients occurs infrequently. The viral RNA load and dynamics of SARS-CoV-2 RNA shedding suggest no relevant route of transmission through the urinary tract.

Incidental finding of prostate cancer in Transurethral Resection of Prostate (TURP) specimens: a retrospective analysis from a Tertiary Care Hospital in Pakistan

Introduction

incidental prostate cancer findings reflect the great burden of prostatic cancer across the globe. Our 10 year retrospective analysis aimed to identify the incidence and clinic-pathologic features of prostate cancer incidentally detected in patients undergoing transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), and to estimate the clinical value of pathologic review of all TURP specimens.

Methods

after excluding patients with a known diagnosis of prostate cancer prior to TURP a total of 2,386 men (ages 25-98) were identified by pathology (TURP) specimens. Yearly incidences, Gleason score, grade, pathologic stage were recorded for all incidental prostate cancer patients.

Results

a total of 256 (10.7%) patients were found to have prostate cancer. Mean Age was 68.51±9.22 years. T1a and T1b stage prostatic carcinoma was found in 9.9% and 90.1% of these patients respectively. Forty-nine percent (49%) patients had higher Gleason scores (>7). After subtracting average incidences between 5-year intervals, a statistical rise of almost 4% was found.

Conclusion

our analysis concludes that a large proportion (10.7%) of patients had incidental prostate cancer and the incidence was increasing in recent years in Pakistan and in comparison, to Asian countries. In Pakistan there is a scarcity of updated national cancer registries. The growing incidence of high Gleason scores requires keen and prompt attention. The diverse ethnic and socioeconomic background of patients propels their propensity towards loss of follow up with already limited tertiary healthcare institutes in Pakistan. This pathologic review of TURP specimens is valuable for Asiatic and non-Asiatic populations.

The significance of a high preoperative PSA level for the detection of incidental prostate cancer in LUTS patients with large prostates

PURPOSE

To evaluate the diagnostic value of a high preoperative PSA level for the detection of incidental prostate cancer (iPCa) in LUTS patients with very large prostates (> 100 cc).

METHODS

We conducted a retrospective analysis of 1125 men treated for LUTS with holmium laser enucleation of the prostate (HoLEP). Patients were stratified according to a preoperative PSA level higher (high PSA; n = 365) or lower than 10 ng/ml (low PSA; n = 760). Preoperative and histopathological parameters were compared between both cohorts. Logistic regression models were used to identify independent predictors of iPCa.

RESULTS

Demographic parameters were similar between both cohorts. The median PSA levels were 14.2 ng/ml (11.5-19.9) and 4 ng/ml (2.4-6.0). The prostate volume was significantly higher in the high PSA group (105 cc vs. 75 cc; p < 0.001). Correspondingly, the PSA density was significantly increased in the high PSA cohort compared to the low PSA cohort (0.14 vs. 0.05; p < 0.001). The overall detection rate of iPCa showed no difference between groups (9.5% vs. 9.9%). More preoperative prostate biopsies were performed in the high PSA group compared to the low PSA group (46.8% vs. 17.6%; p < 0.001). However, the rate of false negative results was comparable between groups (12.7% vs. 11.1%; p = 0.726). In logistic regression models all PSA-related parameters failed to predict iPCa.

CONCLUSIONS

PSA-guided approaches to predict iPCa in LUTS patients with very large prostates are not accurate. This finding is useful in clinical practice for counselling our patients and to prevent unwarranted diagnostic procedures.

Is there a PSA cut-off value indicating incidental prostate cancer in patients undergoing surgery for benign prostatic hyperplasia?

AIM

To investigate incidental prostate cancer (IPCa) rate and to determine prostate specific antigen (PSA) cut-off value indicating PCa in patients who underwent surgery by being diagnosed with benign prostatic hyperplasia (BPH) clinically or by standard prostate biopsy.

METHODS

Data of 317 patients, who underwent transurethral resection of the prostate (TURP) or open prostatectomy (OP) with pre-diagnosis of BPH, were evaluated retrospectively. The examined parameters included patients' demographics, preoperative serum PSA values, digital rectal examination (DRE) findings, surgical method, histopathological findings and Gleason Scores.

RESULTS

A total of 317 patients were included the study. The median age of patients was 69 years (min: 51-max: 79) and the median PSA value was 3.24 ng/dl (min: 0.17-max: 34.9). In 21 patients (6.6%); DRE findings were in favor of malignancy, but prostate biopsy resulted as BPH. While 281 (88.6%) of the patients underwent TURP, 36 (11.4%) underwent open prostatectomy. PCa was detected in 21 (6.6%) patients. PSA was statistically higher in patients who underwent OP compared to patient who underwent TUR-P, 5.9 (min: 1.2 - max: 27.6, IR: 8.7) vs. 2.8 (min: 0.1-max: 34.9, IR: 4.2) ng/dl, p < .001. The rate of IPCa among four PSA group was similar (p = 0.46). There was no difference between the rate of IPCa in patients younger and older than 70 years, (p = 0.11). Please change whole sentence as 'The median PSA level was slightly higher in patients diagnosed with BPH compared to patients diagnosed with IPCa, 3.2 (min: 0.1-max: 34.9) vs. 2.7 (min: 0.3-max: 26.5) ng/dL, p = 0.9.

CONCLUSIONS

IPCa still remains an important clinical problem. We were not able to find any correlation of PSA and age with incidental PCa.

Role of Hiraoka's transurethral detachment of the prostate combined with biopsy of the peripheral zone during the same session in patients with repeated negative biopsies in the diagnosis of prostate cancer

BACKGROUND

Persistent suspicion of prostate cancer (PCa) due to a rising prostate-specific antigen (PSA) level after repeated negative biopsies is a serious challenge in clinical practice.

AIM

To determine the role of Hiraoka’s transurethral detachment of the prostate (TUDP) combined with biopsy of the peripheral zone during the same session in patients with repeated negative biopsies in the diagnosis of PCa.

METHODS

We retrospectively evaluated the records of 10 patients who were eligible for inclusion in our hospital between December 2012 and August 2017. Patient demographics, a family history of PCa, the number of biopsies, prostate volume, pathological examination, and perioperative PSA level were obtained.

RESULTS

Two of 10 patients were pathologically diagnosed with PCa after surgery; the Gleason scores were 4 + 4 and 4 + 3, respectively. Both patients subsequently underwent laparoscopic radical prostatectomy. The median PSA levels preoperatively, and 3 mo and 1 year postoperatively in the other eight patients who were diagnosed with benign prostate hyperplasia after surgery were 19.10 ng/mL, 1.10 ng/mL, and 1.15 ng/mL, respectively. The adjusted P values of the 3-mo and 1-year post-operative PSA level vs pre-operative PSA level were 0.003 and 0.026, respectively. None of the patients had increased PSA levels or PCa detected after a median 35 mo of follow-up.

CONCLUSION

TUDP combined with peripheral zone biopsy may improve the detection rate of PCa in patients with repeated negative biopsies. The PSA level declined rapidly in patients who had negative pathological examinations after TUDP, which remained stable 1 year after surgery.

Incidental prostate cancer after transurethral resection of the prostate: analysis of incidence and risk factors in 458 patients

BACKGROUND

The aim of this study is to evaluate the incidence and risk factors of incidental prostate cancer (IPCA) in a contemporary cohort of lower urinary tract symptoms (LUTS) patients who underwent trans-urethral resection of the prostate (TURP).

METHODS

A series of 458 consecutive patients who underwent TURP were evaluated between January 2016 to June 2018. Evaluated factors included age (years), Body Mass Index (BMI; kg/square meters), treatment with inhibitors of 5-alpha reductase, previous prostate biopsies, basal prostate specific antigen (PSA) levels (ng/mL), serum leukocyte count (×10⁹/L), weight of resected prostate tissue (grams), grade and stage of IPCA. The multivariate logistic regression model evaluated associations of significant clinical factors with the risk of IPCA.

RESULTS

Overall, IPCA was detected in 30 of 454 patients (6.6%). A mean of 21.8 g of tissue was resected. The mean number of positive chips was 5.6 (mean percentage 3.9%) with tumor grade group 1 in 22 cases (73.4%) and tumor stage cT1a in 23 patients (76.7%). On multivariate analysis, independent factors that were positively associated with the risk of IPCA were BMI (odds ratio, OR=1.121; P=0.017) and leukocyte count (OR=1.144; P=0.027).

CONCLUSIONS

In a contemporary cohort of patients undergoing TURP for the treatment of LUTS, the risk of IPCA was not negligible with a rate of being 6.6%. BMI and serum leukocyte count were found to be independent factors that were positively associated with the risk of IPCA.

Accuracy of the preoperative PSA level for predicting clinically significant incidental transitional zone-prostate cancer before endoscopic enucleation of very large adenoma

OBJECTIVE

To analyse the accuracy of high preoperative PSA levels for predicting transitional zone incidental PCa (TZ-PCa) in men with very large prostates.

MATERIALS AND METHODS

Perioperative data from 375 consecutive patients who underwent endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction between July 2013 and December 2018 were retrospectively reviewed. Patients were stratified into three groups according to the preoperative PSA level: low-PSA (< 4 ng/mL), intermediate-PSA (4 ≤ PSA < 10 ng/mL) and high-PSA (≥ 10 ng/mL). Men in each group were propensity score matched by age, 5α-reductase inhibitor (5-ARI) use, prostate volume and mpMRI. The TZ-PCa incidence rate was retrospectively compared by preoperative PSA level in a propensity score model including all predetermined variables.

RESULTS

Age, prostate volume, 5-ARI use were similar between patient groups. The median PSA levels in the low-, intermediate- and high-PSA groups were 3 [2.3; 3.4], 6.6 [5.3; 8.1] and 12.7 [11; 16.7] ng/mL, respectively. The median prostate volume was > 100 grams in all groups (108, 105 and 120 cc, respectively). The T1a-Gleason 6 incidental TZ-PCa rate was statistically comparable between the three groups (3.4, 5.1 and 8.6% in the low-, intermediate- and high-PSA groups, respectively). The detection rate of clinically significant TZ-PCa was low for preoperative PSA levels > 4 ng/mL (1.7%); with no difference between the intermediate- and high-PSA groups.

CONCLUSION

In men with large glands, the clinically significant incidental TZ-PCa detection rate was similar regardless of the preoperative PSA level stratum. Such details may help with patient counselling during BPH surgical management.

Does mechanical morcellation of large glands compromise incidental prostate cancer detection on specimen analysis? A pathological comparison with open simple prostatectomy

OBJECTIVE

This study sought to compare the incidental prostate cancer (iPCa) detection rate between pathological specimens from green laser enucleation of the prostate (GreenLEP) and open simple prostatectomy (OSP).

MATERIALS AND METHODS

In two institutions, the charts of all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and the data of all consecutive patients who underwent GreenLEP with tissue morcellation between July 2013 and January 2018 were also collected. Preoperative demographics and pathological findings were recorded. iPCa detection rate was retrospectively compared between the GreenLEP and OSP groups in a propensity score model, including all predetermined variables: Age, preoperative PSA level and prostate volume.

RESULTS

Of 738 patients, 402 were included in the propensity-score matching analysis, and they were equally distributed among groups. The overall iPCa detection rates were similar in both groups (9.9% vs. 8.5%; p = 0.73), and there were no statistically significant differences in terms of tumour stage, Gleason score or the rate of clinically significant iPCa, although the number of cassettes analysed was significantly higher in the morcellation group than in the OSP group. No predictive factors for iPCa were identified.

CONCLUSIONS

The results of the present study suggest that the mechanical morcellation of large glands had no influence on iPCa detection. Compared with a specimen from standard OSP, a large morcellated tissue sample allows adequate pathological evaluation and does not alter a pathologist's ability to detect iPCa.

Incidental prostate cancer: a 10-year review of a tertiary center, Tehran, Iran

Objective

Incidental prostate cancer (IPCa) is defined as a symptom-free cancer unexpectedly discovered upon microscopic examination of resected tissue. The aim of this study was to report the correlation between some specific clinical criteria in patients incidentally diagnosed with prostate cancer (PCa) during transurethral resection of the prostate (TURP) or open prostatectomy (OP) after clinically suspected benign prostatic hyperplasia.

Patients and methods

This was a cross-sectional, retrospective study. Data were collected from Shohada-e-Tajrish Hospital database during November 2006 to October 2016. Four hundred and twenty three men suffering from symptomatic benign prostatic hyperplasia who underwent either TURP or OP that provided a prostate specimen were evaluated. The data analysis was performed using Pearson correlation test and independent t-test using SPSS version 20 software.

Results

The mean age of subjects was 68.74±9.87 years old (45-93 years). The mean prostate specific antigen (PSA) level was 21.47±13.44 ng/mL (0.6-47.1 ng/mL). Results showed that 84 patients (19.9%) had PCa (40 patients who underwent TURP [12.6%] and 44 patients who underwent OP [40.7%] groups). Cut-off point of PSA for detecting IPCa was 3.8 ng/mL in our study, and this showed sensitivity, specificity, negative predictive value, and positive predictive value of 26.08%, 100%, 100%, and 29.79%, respectively. Twenty two patients with cancer had a positive family history for PCa; thus, a significant relationship between familial history of PCa and its occurrence was shown (p=0.0001).

Conclusion

According to the results of this study, the cut-off point for PSA levels in detecting PCa was 3.8 ng/mL, which is similar to that reported by other studies. Familial history of PCa and PSA levels were two predictors in determining the PCa.

Incidental prostate cancer in transurethral resection of prostate specimens in men aged up to 65 years

Background

The identification of prostate cancer (PC) is important in men aged ≤ 65 years. We examined complete transurethral resection of prostate (TURP) specimens to quantify the incidence and nature of PC in men aged ≤ 65 years.

Methods

A prospective multi-institutional database included TURP specimens. The cohort was stratified into two groups according to age. For men aged ≤ 65 years, the entire specimen was submitted for histological analysis, while the TURP specimens from men aged > 65 years were sampled following standard guidelines.

Results

A total of 923 men were included, with 224 in the younger group. PC was identified in 13.4% in men aged ≤ 65 years, compared with 28.7% the older group. The younger group had a lower proportion of Gleason score ≥ 7 (30% compared with 40%) and higher rates of pT1a (57% compared with 43%). In men aged ≤ 65 years with cancer, tumor was identified in one block in 15 of 30 cases (50%). Following diagnosis, 4/30 underwent radical prostatectomy, 5/30 underwent curative radiotherapy, 10/30 androgen deprivation, and 1/30 received palliative radiotherapy.

Conclusion

Incidental PC in men aged ≤ 65 years is not uncommon. Our results suggest that TURP specimens in men aged ≤ 65 years should be completely assessed. Underidentification of cancer may occur as a result of increasing use of laser prostatectomy and the consequent loss of tissue for pathological examination.

Should all specimens taken during surgical treatment of patients with benign prostatic hyperplasia be assessed by a pathologist?

INTRODUCTION

In some patients submitted to transurethral resection of the prostatic (TURP) or prostatectomy (OAE) due to benign prostate hyperplasia (BPH), pathological evaluations (PE) revealed coexistence of prostate cancer (PCa) and BPH. The aim of the study is to evaluate the incidence of PCa diagnosed incidentally in prostate specimens taken during BPH surgery, to assess the need of routine PE and to define the group of patients in whom PE could be abandoned without the risk of omitting clinically significant PCa.

MATERIAL AND METHODS

968 consecutive men were subjected to surgical treatment due to BPH in Jan. 2004-Sep. 2010.

RESULTS

823 (85%) underwent TURP and 145 (15%) OAE. Incidental (Inc) PCa was diagnosed in 34(3.5%) pts. T1a and T1b stages were determined in 19 (2%) and 15 (1.5%) cases. Preoperative prostate biopsy due to abnormal prostate specific antigen (PSA) or digital rectal exam (DRE) was performed in 85 (8.8%) pts. Of PCa pts, 7 (20.58%) had undergone a cancer negative biopsy preoperatively. In BPH pts, 78 (8.35%) had undergone a prostate biopsy previously (p <0.01). Univariate and logit regression analyses had not revealed any correlations between age, Pv, serum PSA and frequency of IncPCa. The difference in rate of PCa diagnosed in patients with PSAD ≥0.15 and <0.15 was 8 pts (14.04%) and 20 pts (4.05%), respectively (p <0.001). Gls in those pts was >6 only in 4 cases.

CONCLUSIONS

Despite the fact of low PCa detection rate observed in our study, this condition was clinically relevant in 15 (1.5%) subjects. It is difficult to establish any cut off values of pts' age, Pv, serum PSA level suggestive of negligible risk for prostate cancer.

Incidental prostate cancer in transurethral resection of the prostate specimens in the modern era

Objectives. To identify rates of incidentally detected prostate cancer in patients undergoing surgical management of benign prostatic hyperplasia (BPH). Materials and Methods. A retrospective review was performed on all transurethral resections of the prostate (TURP) regardless of technique from 2006 to 2011 at a single tertiary care institution. 793 men (ages 45-90) were identified by pathology specimen. Those with a known diagnosis of prostate cancer prior to TURP were excluded (n = 22) from the analysis. Results. 760 patients had benign pathology; eleven (1.4%) patients were found to have prostate cancer. Grade of disease ranged from Gleason 3 + 3 = 6 to Gleason 3 + 4 = 7. Nine patients had cT1a disease and two had cT1b disease. Seven patients were managed by active surveillance with no further events, one patient underwent radiation, and three patients underwent radical prostatectomy. Conclusions. Our series demonstrates that 1.4% of patients were found to have prostate cancer, of these 0.5% required treatment. Given the low incidental prostate cancer detection rate, the value of pathologic review of TURP specimens may be limited depending on the patient population.