[Transrectal ultrasound of the prostate. Current status and prospects]

[Core needle biopsy twice negative with rising PSA level. Does imaging help?]

In compliance with guidelines in cases of suspected prostate cancer, the standard approach involves transrectal ultrasound-guided systematic biopsies. Currently, according to the new S3 guideline for prostate cancer, 10-12 tissue samples should be collected per patient and session. If these primary specimens are negative, the number of multiple biopsies is generally increased in the second session to improve the diagnostic certainty with more biopsies. At the latest when the second core needle biopsy is performed in the presence of rising prostate-specific antigen (PSA) level, an attempt is made to minimize the risk of overlooking prostate cancer by further increasing the number of multiple biopsies in the sense of achieving saturation. In this instance, the number ranges from 6 to 143 tissue samples per session. Studies have provided evidence that after two systematic random biopsies the same number of additional random biopsies does not accomplish any essential improvement of diagnostic certainty. There are hardly any studies in the literature dealing with the role of imaging procedures after negative prostate biopsies. In a prospective clinical trial including 132 patients with an average of 12 negative previous biopsies, a dramatically high number of prostate carcinomas (66 of 132) could be detected with innovative imaging (1-6 targeted biopsies). This raises the question of how reliably multiple systematic biopsies can in fact exclude the presence of cancer. Thus, particularly after a negative series of multiple biopsies, it appears to be expedient to use specific imaging to enhance diagnostic certainty through quality. However, prospective clinical validation of the diverse innovative methods seems to be important before broad application.

[Transrectal sonography biofeedback training (TSB). Incontinence training after radical prostatectomy]

BACKGROUND

Biofeedback methods are used in severe incontinence after radical prostatectomy (RP). Although contraction of the urethral sphincter can be demonstrated very well to the patient by video urethrocystoscopy, this method is invasive. Transrectal sonography biofeedback training (TSB) is a less invasive method for visualization of contractions of the musculus sphincter urethrae externus.

PATIENTS AND METHODS

A total of 100 patients with urinary incontinence after RP either lost 50 g urine or more during a 1-h pad test or they could not feel their sphincter contraction during physiotherapy continence training. Patients lying on their left side followed the examination with a 7.5-MHz ultrasound probe on a second monitor. Patients were then asked to reduce the urinary stream for 5 s with 10%, 30%, 70% and 100% of maximum possible strength. A reduction in the diameter of the fluid column just above the sphincter urethrae externus proportional to the strength of contraction could be demonstrated to the patients.

RESULTS

Pain prevented TSB in 8%; 8% reported on severe, 5% on moderate and 24% on mild pain. In 4% the sphincter could not be precisely detected. A total of 88% showed differentiated tension, while 96% claimed that TSB was helpful for restoring continence after radical prostatectomy.

CONCLUSION

TSB, particularly in the transversal plane, is a viable method to treat urinary incontinence after radical prostatectomy. In 8% of patients pain prevented TSB, in 4% TSB did not lead to evaluable results, while in 88% TSB demonstrated the effects of different tension strength of the sphincter muscle to the patients. The method is very well accepted by the patients themselves.