Transdermal oestradiol for androgen suppression in prostate cancer: long-term cardiovascular outcomes from the randomised Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme

BACKGROUND

Androgen suppression is a central component of prostate cancer management but causes substantial long-term toxicity. Transdermal administration of oestradiol (tE2) circumvents first-pass hepatic metabolism and, therefore, should avoid the cardiovascular toxicity seen with oral oestrogen and the oestrogen-depletion effects seen with luteinising hormone releasing hormone agonists (LHRHa). We present long-term cardiovascular follow-up data from the Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme.

METHODS

PATCH is a seamless phase 2/3, randomised, multicentre trial programme at 52 study sites in the UK. Men with locally advanced or metastatic prostate cancer were randomly allocated (1:2 from August, 2007 then 1:1 from February, 2011) to either LHRHa according to local practice or tE2 patches (four 100 μg patches per 24 h, changed twice weekly, reducing to three patches twice weekly if castrate at 4 weeks [defined as testosterone ≤1·7 nmol/L]). Randomisation was done using a computer-based minimisation algorithm and was stratified by several factors, including disease stage, age, smoking status, and family history of cardiac disease. The primary outcome of this analysis was cardiovascular morbidity and mortality. Cardiovascular events, including heart failure, acute coronary syndrome, thromboembolic stroke, and other thromboembolic events, were confirmed using predefined criteria and source data. Sudden or unexpected deaths were attributed to a cardiovascular category if a confirmatory post-mortem report was available and as other relevant events if no post-mortem report was available. PATCH is registered with the ISRCTN registry, ISRCTN70406718; the study is ongoing and adaptive.

FINDINGS

Between Aug 14, 2007, and July 30, 2019, 1694 men were randomly allocated either LHRHa (n=790) or tE2 patches (n=904). Overall, median follow-up was 3·9 (IQR 2·4-7·0) years. Respective castration rates at 1 month and 3 months were 65% and 93% among patients assigned LHRHa and 83% and 93% among those allocated tE2. 157 events from 145 men met predefined cardiovascular criteria, with a further ten sudden deaths with no post-mortem report (total 167 events in 153 men). 26 (2%) of 1694 patients had fatal cardiovascular events, 15 (2%) of 790 assigned LHRHa and 11 (1%) of 904 allocated tE2. The time to first cardiovascular event did not differ between treatments (hazard ratio 1·11, 95% CI 0·80-1·53; p=0·54 [including sudden deaths without post-mortem report]; 1·20, 0·86-1·68; p=0·29 [confirmed group only]). 30 (34%) of 89 cardiovascular events in patients assigned tE2 occurred more than 3 months after tE2 was stopped or changed to LHRHa. The most frequent adverse events were gynaecomastia (all grades), with 279 (38%) events in 730 patients who received LHRHa versus 690 (86%) in 807 patients who received tE2 (p<0·0001) and hot flushes (all grades) in 628 (86%) of those who received LHRHa versus 280 (35%) who received tE2 (p<0·0001).

INTERPRETATION

Long-term data comparing tE2 patches with LHRHa show no evidence of a difference between treatments in cardiovascular mortality or morbidity. Oestrogens administered transdermally should be reconsidered for androgen suppression in the management of prostate cancer.

FUNDING

Cancer Research UK, and Medical Research Council Clinical Trials Unit at University College London.

The changes in prostate cancer and its management in the North West of England over a 10-year period

Objectives:

Our aim was to evaluate changes in prostate cancer diagnosis and management and to examine changes in the stage and grade of newly diagnosed prostate cancer in the North West of England over a 10-year period.

Materials and methods:

Data was collected concerning the diagnosis (including stage and grade) and management of newly diagnosed prostate cancer in the North West of England. There were three time points: 2003, 2007 and 2011 including a total of 648 patients. For assessment of median time changes Spearman’s Rank correlation test was used, for the assessment of changes in Gleason grade and clinical stage Mann–Whitney U test was used, and assessment of positive margin rates was done with Fisher’s test.

Results:

Median time from management decision to surgery has reduced from 46 (2003), 34 (2007) to 27 days (2011) ( p=0.074). The proportion of patients managed with active surveillance has remained relatively constant over time (18%, 16% and 21% respectively). More minimally invasive, nerve-sparing prostatectomies are now performed, and positive margin rates have significantly reduced from 53% (2003) to 23% (2011) ( p<0.001). Gleason grade significantly increased over time ( p<0.001); Gleason 7 disease was diagnosed in 23% of patients in 2003, 32% in 2007 and 49% in 2011 ( p<0.001). There was an increase in Gleason 8 disease; 6% (2003) to 8.6% (2011), but this was not significant ( p=0.27). Increase in clinical stage was also noted over time; identification of T3 disease rose from 2% (2003 and 2007) to 5% (2011) ( p=0.045) (excluding cases with non-recorded stage).

Conclusion:

Prostate cancer management in the North West of England has evolved over the last decade, with overall improvements in management quality. We have demonstrated an increase in the presenting stage and grade of prostate cancer over a 10-year period.

Prevalence of prostatic calcification subtypes and association with prostate cancer

OBJECTIVE

To evaluate the prevalence and to classify prostatic calcification on transrectal ultrasonography (TRUS) and correlate the findings with histology.

METHODS

A prospective, blinded study of men undergoing TRUS and prostatic biopsy was designed. A standardized reproducible technique was used with a BK 7.5- to 12.5-MHz multiplanar probe. Representative images of the calcification in the sagittal and transverse planes were captured. Blind analysis by an experienced observer was performed. TRUS findings were categorized using a novel classification and correlated with histologic data.

RESULTS

A total of 274 patients (58.8%) had prostate cancer, 88 patients (18.9%) inflammation, and 104 patients (22.3%) had benign pathology. Interface calcification was present in 42.3% of patients. Peripheral or transitional zone calcification was unusual (6.8% and 9.0%, respectively). Of the peripheral zone calcification group patients, 78.1% had cancer on histology examination (P = .020).

CONCLUSION

Prevalence and characteristics of prostatic calcification have been described using this novel and practical classification. Although interface calcification is common and not associated with any particular pathology, peripheral zone calcification appears to be strongly associated with prostate cancer.

Embryology and adult urology - Not always mutually exclusive: A case report on true hermaphroditism at an adult urology clinic

True hermaphrodite (TH) is one of the rarest varieties of disorders of sexual differentiation. Most patients present early in the life and are managed by pediatricians. We present a rare case of an adult TH which was first diagnosed by a urologist. We discuss the pathology of TH and its clinical relevance. Knowledge and awareness of embryology are vital to all specialties.

A rare case of testicular metastasis of bladder transitional cell carcinoma

Metastases from bladder transitional cell carcinoma (TCC) to the testis are very rare. These are usually found on autopsy and occur in advanced or metastatic bladder cancers. More common, known primary tumors that metastasize to the testis include prostate, lungs, melanoma, gastro-intestinal tract and the kidney. We report a rare case of solitary and synchronous metastatic TCC of the bladder to the testis, discovered on histological examination. This case illustrates that metastatic neoplasm to uncommon sites should be considered in the differential diagnosis for patients with a history of advanced bladder TCC.

Acute urinary retention in women due to urethral calculi: A rare case

We present a case of a 51-year-old woman with acute urinary retention caused by a urethral calculus. Urethral calculi in women are extremely rare and are usually formed in association with underlying genitourinary pathology. In this case, however, no pathology was detected via thorough urological evaluation. We discuss the pathogenesis, clinical presentation and treatment of urethral calculi. To our knowledge, this is the second reported case of a primary urethral calculus in a female with an anatomically normal urinary tract and the first in a middle-aged Caucasian female.

Diethylstilboestrol for the treatment of prostate cancer: past, present and future

The aim of this review was to discuss the most recent data from current trials of diethylstilboestrol (DES) to identify its present role in advanced prostate cancer treatment as new hormonal therapies emerge. The most relevant clinical studies using DES in castration-refractory prostate cancer (CRPC) were identified from the literature. The safety, efficacy, outcomes and mechanisms of action are summarized. In the age of chemotherapy this review highlights the efficacy of oestrogen therapy in CRPC. The optimal point in the therapeutic pathway at which DES should be prescribed remains to be established.

Bladder neck sparing in radical prostatectomy

The role of a bladder neck sparing (BNS) technique in radical prostatectomy (RP) remains controversial. The potential advantages of improved functional recovery must be weighed against oncological outcomes. We performed a literature review to evaluate the current knowledge regarding oncological and functional outcomes of BNS and bladder neck reconstruction (BNr) in RP. A systematic literature review using on-line medical databases was performed. A total of 33 papers were identified evaluating the use of BNS in open, laparoscopic and robotic-assisted RP. The majority were retrospective case series, with only one prospective, randomised, blinded study identified. The majority of papers reported no significant difference in oncological outcomes using a BNS or BNr technique, regardless of the surgical technique employed. Quoted positive surgical margin rates ranged from 6% to 32%. Early urinary continence (UC) rates were ranged from 36% to 100% at 1 month, with long-term UC rate reported at 84-100% at 12 months if the bladder neck (BN) was spared. BNS has been shown to improve early return of UC and long-term UC without compromising oncological outcomes. Anastomotic stricture rate is also lower when using a BNS technique.

Early prostate cancer--which treatment do men prefer and why?

STUDY TYPE

Preference (prospective cohort).

LEVEL OF EVIDENCE

1b. What's known on the subject? and What does the study add? In general the literature suggests that there is a need for improvement in aiding men diagnosed with early prostate cancer in their decision making about treatment options and that our understanding of this process is inadequate. There is limited data analyzing the reasons why these men decide between potentially curative or observational treatments and data evaluating patients' views before and after definitive therapy are scarce. This study begins the process of understanding the reasons underlying a patient's final treatment decision. Being a prospective study, it looks at the thought processes of these men before treatment during the time the decision is made. It also documents how satisfied patients are with their choice after their treatment and whether they would choose the same treatment again.

OBJECTIVE

To identify the reasons for patients with localised prostate cancer choosing between treatments and the relationship of procedure type to patient satisfaction post-treatment.

PATIENTS AND METHODS

768 men with prostate cancer (stage T1/2, Gleason≤7, PSA<20 ug/L) chose between four treatments: radical prostatectomy, brachytherapy, conformal radiotherapy and active surveillance. Prior to choosing, patients were counselled by a urological surgeon, clinical (radiation) oncologist and uro-oncology specialist nurse. Pre-treatment reasons for choice were recorded. Post-treatment satisfaction was examined via postal questionnaire.

RESULTS

Of the 768 patients, 305 (40%) chose surgery, 237 (31%) conformal beam radiotherapy, 165 (21%) brachytherapy and 61 (8%) active surveillance. Sixty percent of men who opted for radical prostatectomy were motivated by the need for physical removal of the cancer. Conformal radiotherapy was mainly chosen by patients who feared other treatments (n=63, 27%). Most men chose brachytherapy because it was more convenient for their lifestyle (n=64, 39%). Active surveillance was chosen by patients for more varied reasons. Post-treatment satisfaction was assessed in a subgroup who took part in the QOL aspect of this study. Of the respondents to the questionnaire, 212(87.6%) stated that they were satisfied/extremely satisfied with their choice and 171(92.9%) indicated they would choose the same treatment again.

CONCLUSION

Men with early prostate cancer have clear reasons for making decisions about treatment. Overall, patients were satisfied with the treatment and indicated that despite different reasons for choosing treatment, they would make the same choice again.

The '2-week wait' rule for referrals for suspected urological cancers--urgent need for refinement of criteria

INTRODUCTION

All NHS-suspected cancers should be seen within 2 weeks of referral and are referred under government guidelines (Health Service Circular 205; HSC 205). This policy will be subject to review in 2009. Review is vital to allow the appropriate detection of malignancy without overburdening the premium clinic slots with the healthy.

PATIENTS AND METHODS

A total of 170 consecutive patients were referred from January-June 2005. Referral details, patient information, events and time to diagnosis were recorded.

RESULTS

Of these 170 patients, 143 were suitable for analysis. Forty-three patients (30%) were referred with frank haematuria, of whom 30% had bladder cancer. Nine percent of patients (n = 13) had microscopic haematuria none of whom had cancer. A quarter of the patients (n = 35) were referred with suspected testis cancer but none had cancer. Forty-one patients were referred with serum prostate-specific antigen (PSA) elevation; 18 cancers were detected in this group. Ten men had PSA values greater than 50 ng/ml. Only two cancers were suitable for radical prostatectomy. No cancer was found in patients less than 50 years of age.

CONCLUSIONS

A high cancer incidence was found (27.9%), the majority of which was bladder cancer or advanced prostate cancer. Out of the 143 patients, no malignancy was diagnosed in any patient less than 50 years of age, no malignancy was diagnosed in any of the microscopic haematuria group and there was no cancer diagnosed in the group of patients referred with scrotal swellings. We suggest that some guidelines are leading to referral of patients with low cancer risk. When the HSC 205 is revised in 2009, we hope studies such as ours are taken into consideration in order to improve resource utilisation.

Long-term results of extracorporeal shockwave therapy for Peyronie's disease

PURPOSE

To analyze the long-term results in patients undergoing extracorporeal shockwave therapy (ESWT) for Peyronie's disease.

PATIENTS AND METHODS

Patients treated with ESWT (3000 shockwaves on a Storz Minilith SL lithotripter) for Peyronie's disease were included. The mean disease duration prior to treatment was 23.2 months (range 4-60 months). Penile angulation was measured before and after treatment by artificial vacuum induction of erection. Pain during erection was measured using a visual analog scale (VAS 0-5). The average number of ESWT sessions was 3.4 (range 2-9). The mean follow-up post-treatment was 44.1 months (range 42-48 months). Of 44 eligible patients, 38 patients (86.4%) were contactable for evaluation.

RESULTS

Of the 38 patients, 10 (26%) subsequently underwent corrective surgery for failed ESWT. Of the remaining 28 patients, 18 (47% of the total) had a statistically significant reduction in angulation, with a mean reduction of 33.2 degrees +/- 14.4 degrees (SD) (range 10 degrees -75 degrees ) (P < 0.001). Nine patients (24%) obtained no benefit, and one had an increase in angulation of 10 degrees . Of the 24 patients with pain, 16 (66.6%) reported relief after ESWT, the mean reduction being 2.5 (range 0.5-4.0) on the VAS (P < 0.001). Of the 28 patients who had not undergone surgical correction, 18 (65%) reported erections suitable for intercourse; 14 (48%) were satisfied with ESWT, 8 (30%) dissatisfied, and 6 (22%) uncertain. Although one patient complained of some penile shortening, no other long-term adverse events were noted.

CONCLUSION

Although a quarter of ESWT patients resorted to surgery, in the absence of other effective nonsurgical treatments, ESWT may provide a useful, safe, conservative management option. Extracorporeal shockwave therapy cannot yet be recommended as standard for Peyronie's disease, and randomized controlled studies are required to validate its efficacy and identify the subset of patients most likely to benefit.

Diethylstilboestrol versus bicalutamide in hormone refractory prostate carcinoma: a prospective randomized trial

OBJECTIVE

To compare the efficacy of diethylstilboestrol (DES) with bicalutamide in the treatment of hormone refractory prostate cancer in relation to its effect on prostate-specific antigen (PSA) and survival.

METHODS

Patients on LHRH analogues for prostate carcinoma with evidence of biochemical or clinical progression were randomized into one of the treatment arms (n=58). The first group (group A, n=26) received 1 mg of DES with 75 mg of aspirin per day in addition to the primary hormonal treatment. The second group (group B, n=32) received bicalutamide at a dose of 50 mg/day in addition to the primary treatment. Patients were followed up every 3 months with their PSA being checked and were also monitored for any clinical progression and adverse effects as a result of treatment. Any adverse event occurring after patients were started on treatment was attributed to the drug and patients were clinically assessed at each visit. Failure of treatment was defined as a 50% or greater increase in PSA after commencing treatment. Once randomized, all patients were followed up for survival regardless of failure of second-line hormonal manipulation.

RESULTS

The mean age of the patients was 76.7 years (60-88, SD 7.4) in group A and 76 years (67-86, SD 6.9) in group B. Twelve patients in each group had metastatic disease. The median follow-up periods for both groups were 24 months (range 6-48 in group A, range 3-54 in group B). 65% of the patients in group A (17/26) and 43.5% (14/32) in group B had a fall in their PSA levels (p=0.08, Fisher's exact test) with 23% (6/26) and 31% (10/32) having a >50% response respectively (p=0.34, Fisher's exact test). Mean PSA nadir in those who responded were 20.6 ng/ml (range 1.6-59.4) and 7.41 ng/ml (range 0.1-42.6) in groups A and B respectively. The median duration of response was 9 months (3-18 months) for group A and 12 months (3-18 months) for group B. Seven patients in group A and 6 in group B experienced adverse events. Three of the 7 in the group A experienced cardiovascular related adverse effects (1 congestive cardiac failure, 1 pulmonary embolism and 1 stroke). At the end of the study period, 14 (54%) of group A patients were alive and 12 (46%) were dead. In group B, 15 (47%) were alive, 16 (50%) were dead and 1 (3%) lost to follow-up. At the completion of the study, 3 patients in each group were still on treatment.

CONCLUSION

Low-dose DES and 50 mg of bicalutamide per day are equally effective in hormone refractory prostate carcinoma with respect to biochemical response, although DES has more severe adverse effects. This is a small sample and larger multicentre trials are needed to give us a definite conclusion.

TROPONIN T AND N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE CHANGES IN PATIENTS UNDERGOING TRANSURETHRAL RESECTION OF THE PROSTATE

PURPOSE

We investigated whether transurethral resection of the prostate (TURP) caused subclinical myocardial damage or cardiac dysfunction by measuring troponin T (Trop T) and N-terminal pro-brain natriuretic peptide (pro-BNP).

MATERIALS AND METHODS

A total of 52 consenting patients took part in this study. All had a detailed medical history including cardiac history taken. On the day of the operation all patients had troponin T, pro-BNP, full blood count and urea, electrolytes and creatinine measured preoperatively. A preoperative and postoperative electrocardiogram was performed. Patients in renal failure were excluded from analysis. During the operations factors such as blood loss, operative time, tissue resected and fluid absorption were monitored. On postoperative day 1 all the previously mentioned tests were repeated.

RESULTS

Mean patient age was 71 years (range 52 to 85). Eight patients had a history of associated cardiac problems. Mean preoperative and postoperative hemoglobin were 14.1 gm/dl (range 10.5 to 17) and 13.3 gm/dl (range 9.9 to 16.2), respectively. None of the patients had significant (greater than 1,000 ml) fluid absorption during TURP, which was calculated using ethanol tagged glycine. Mean blood loss measured with a photometer was 129.7 ml (range 0 to 1,800). Mean operative time was 28.4 minutes (range 5 to 50) and mean weight of prostatic tissue resected was 15.2 gm (range 1 to 47). Preoperative Trop T was less than 0.01 mcg/ml in all patients and mean pro-BNP was 39.2 pg/ml (range 0.5 to 866). Postoperative Trop T was less than 0.01 mcg/ml in all but 1 patient who experienced chest pain after TURP and had an increased Trop T (0.28 mcg/ml). Mean postoperative pro-BNP was 54.57 pg/ml (range 1 to 679). A total of 37 patients had an increase in pro-BNP which was still within the reference range for the age group. There were no significant electrocardiogram changes postoperatively. The Trop T changes were not statistically significant (Wilcoxon sign ranked test p = 0.31) although they may be clinically significant.

CONCLUSIONS

Our study indicates that in patients with no prior cardiac history TURP does not cause myocardial damage indicated by nonincrease of Trop T. There are slight increases in pro-BNP after TURP in some patients although the exact clinical significance is uncertain.

Ureteric obstruction caused by aneurysm of the hypogastric artery

We present the case of a 70-year-old man with haematuria who was found to have an internal iliac artery aneurysm causing ureteric obstruction. Urgent repair of the iliac artery aneurysm was performed but no urological intervention was necessary.

Early and late morbidity after vasectomy: a comparison of chronic scrotal pain at 1 and 10 years

OBJECTIVE

To evaluate the incidence and timing of the onset of chronic scrotal pain after vasectomy in two populations at 1 and 10 years after surgery.

PATIENTS AND METHODS

In a retrospective questionnaire-based study two groups of men were compared; 460 who had a vasectomy in 1991-92 (group A) and another 460 who had a vasectomy in 2000-1 (group B; 10 and 1 year after surgery, respectively). Data were collected on immediate complications, and the incidence and nature of chronic scrotal pain. Pain severity was graded using a visual analogue score (VAS). Patients were also asked if they regretted having a vasectomy because of pain.

RESULTS

In all, 182 and 220 replies were received from patients in group A and B, respectively. Early complications included haematoma in five (2%) and two (0.9%) patients, respectively, and wound infection in 24 (13%) and 17 (7.7%). Eight patients who had scrotal pain even before vasectomy were excluded from the analysis (two in group A and six in group B). In group A, 25 of 180 (13.8%) had a new onset of scrotal pain of some nature, with eight (4.3%) having a VAS of > 5; one patient had an epididymectomy for this. Three of the 25 regretted having a vasectomy because of pain. In group B, 36 of 214 (16.8%) reported persistent scrotal pain, with 13 (5.9%) having a VAS of > 5. Six of the 36 regretted having a vasectomy because of the pain. The incidence of scrotal pain was not significantly different between the groups (P = 0.48, Fisher's exact test).

CONCLUSION

Chronic scrotal pain after vasectomy is more common than previously described, affecting almost one in seven patients. All patients undergoing vasectomy must receive appropriate preoperative counselling about this. The incidence of this complication does not appear to increase with time.

Management of acute urinary retention secondary to benign prostatic hyperplasia in the UK: a national survey

OBJECTIVE

To analyse current practice in the management of acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) in the UK, and to assess how much of this is evidence-based.

METHODS

In all, 410 consultant urologists practising in UK hospitals were sent a questionnaire about the management of AUR secondary to BPH. Data were collected on practice relating to initial management, trial without catheter (TWOC), the use of alpha-blockers and the follow-up. The need for a uniform guideline in the management of AUR secondary to BPH was also assessed.

RESULTS

We received 270 (66%) replies, of which six were excluded because they were from subspeciality interests (e.g. paediatric urology) or had ambiguous answers; 264 (64%) were therefore available for analysis. Urethral catheterization was the initial management of choice (98%), failing which a suprapubic catheter was inserted. Two-thirds (65.5%) admitted the patient after catheterization. Most consultants initiated alpha-blockers (70.5%), with 64% (118) of these using a TWOC 2 days after starting them. One failed TWOC was an indication for transurethral resection of the prostate for 192 (72.8%), with 136 (49.8%) re-admitting the patient for surgery later. Routine follow-up after a successful TWOC was advocated by 77.3%. Just over half the respondents (52.6%) felt that there was no need for uniform guidelines in the management of AUR secondary to BPH.

CONCLUSION

This survey identified a reasonable national uniformity in managing AUR secondary to BPH in the UK, but significant aspects of current practice are not evidence-based.

Nitrous Oxide vs Periprostatic Nerve Block With 1% Lidocaine During Transrectal Ultrasound Guided Biopsy of the Prostate: A Prospective, Randomized, Controlled Trial

PURPOSE

We compared the efficacy of Entonox (BOC Gases, Manchester, United Kingdom), a mixture of 50% nitrous oxide and oxygen, with periprostatic infiltration of 1% lidocaine to provide analgesia during transrectal ultrasound (TRUS) guided biopsy of the prostate.

MATERIALS AND METHODS

The study included 235 consecutive men undergoing TRUS guided biopsy of the prostate for elevated prostate specific antigen or abnormal digital rectal examination. Patients were randomized to 3 groups, including group 1-84 controls who did not receive any form of analgesia prior to the procedure, group 2-75 who received periprostatic infiltration with 10 ml 1% lidocaine with biopsies performed 5 minutes after infiltration and group 3-76 who received Entonox for 2 minutes through a breath activated device prior to the procedure and thereafter according to patient preference. All patients were asked to indicate the level of pain experienced before and after the procedure on a 10 cm, nonnumerical, horizontal visual analog score. Results were analyzed using 1-way ANOVA.

RESULTS

Mean patient age was 68.8, 64.9 and 65.2 years, and mean visual analog score was 2.9, 1.6 and 2.2 in groups 1 to 3, respectively. Patients in groups 2 (1% lidocaine infiltration) and 3 (Entonox) experienced significantly less pain during the procedure compared with group 1 controls (p <0.001 and 0.028, respectively). There was no statistical difference in pain scores between groups 2 and 3 (p = 0.08).

CONCLUSIONS

Inhalation of Entonox or periprostatic infiltration with 1% lidocaine can be used for analgesia during TRUS guided biopsy of the prostate since each provides significant and similar pain relief.

Partner's influence on patient preference for treatment in early prostate cancer

OBJECTIVE

To determine the partner's influence on the patient's choice of treatment for early prostate cancer, and whether partner characteristics and biases predict the preference.

PATIENTS, SUBJECTS AND METHODS

Questionnaires for partners to complete retrospectively were sent to consecutive patients recruited in a study comparing treatment options for early prostate cancer. The partners' perceptions about prostate cancer were explored and the partners asked to comment on the suitability of each treatment option. Partners recorded their influence on the patient's choice using a 10-point visual linear analogue scale.

RESULTS

Questionnaires were sent to 116 eligible patients and 82 were returned for analysis (mean partner age 63 years). When asked to recall the treatment options initially discussed, all partners recalled radiotherapy (EBRT), all but one radical prostatectomy (RP), 51% brachytherapy, but only 29% watchful waiting (WW); 41% of partners stated RP as their chosen option, 37% EBRT, 12% brachytherapy and 10% no clear favourite. None preferred WW. Employment and education status were not significant predictors of partners' preference but retired partners and those aged > 65 years were 3 times more likely to prefer EBRT than were their employed and younger counterparts, respectively. The partners' mean (median, SD) self-assessed influence factor was 4.8 (5, 3.4). Of the partners, 88% reported active involvement throughout the process, identifying information-gathering and emotional support as their primary roles. Most deliberately chose not to influence the patient's final decision.

CONCLUSION

Partner preference is influenced by pre-existing conceptions about cancer and its treatment. While undoubtedly influential throughout the decision-making process, partners deliberately left the final decision to the patient.

Over expression of metallothionein predicts resistance of transitional cell carcinoma of bladder to intravesical mitomycin therapy

PURPOSE

Metallothionein, a low molecular weight intracellular protein, binds mitomycin with high affinity protecting the tumor DNA. We prospectively studied the relationship of metallothionein expression in bladder transitional cell carcinoma and resistance to intravesical mitomycin.

MATERIALS AND METHODS

A series of 45 consecutive patients with superficial transitional cell carcinoma treated with intravesical mitomycin were studied. Resected tumor tissues were stained with metallothionein monoclonal antibody E9. Two pathologists scored staining intensity and distribution. All patients were followed with regular flexible cystoscopy.

RESULTS

Median patient age was 73 years (range 44 to 89). Tumor grade was 1 to 3 in 6, 33 and 6 cases, respectively. In 20 patients (44.44%) tumor recurred after mitomycin therapy. Median cytoplasmic staining scores for recurrent and nonrecurrent tumors were 5 (range 0 to 61) and 0 (0 to 14), respectively. Median nuclear staining scores for recurrent and nonrecurrent tumors were 3 (range 0 to 56) and 0 (0 to 11), respectively. Median followup of patients without recurrence was 18 months (range 12 to 36). Nuclear and cytoplasmic staining scores were significantly higher in recurrent than in nonrecurrent tumors. There was no significant relationship of metallothionein expression with tumor grade.

CONCLUSIONS

Over expression of metallothionein predicts the resistance of bladder transitional cell carcinoma to intravesical mitomycin therapy.

Periprostatic nerve block gives better analgesia for prostatic biopsy

OBJECTIVE

To prospectively compare two local anaesthetic techniques for prostatic biopsies, which are usually taken with no anaesthesia; because multiple biopsy techniques are becoming more common and there is an increasing need for analgesia/anaesthesia during the procedure.

PATIENTS AND METHODS

The study group comprised 86 consecutive men (median age 67.7 years) undergoing prostatic biopsy because of either an abnormality of prostate specific antigen level or digital rectal examination. They were randomized into four groups; men in group 1 received 10 mL of 1% lignocaine infiltrated into the periprostatic nerve plexus bilaterally; men in group 2 received 11 mL of 2% lignocaine gel rectally; men in groups 3 and 4 were recruited as controls, and given either plain gel rectally or an injection with saline into the periprostatic nerve plexus. Sextant prostate biopsies were taken in all cases using a standardized protocol. Immediately after the procedure patients were asked to indicate the degree of pain on a 10-cm visual analogue scale.

RESULTS

Men in group 1 had significantly less pain than the others (P < 0.001). There was no statistically significant difference in pain between men who received plain gel rectally or saline injection (P = 0.35). The rectal instillation of 2% lignocaine gel did not reduce pain significantly (P = 0.186) compared with the controls.

CONCLUSION

A periprostatic nerve block with 1% lignocaine was associated with significantly less pain during prostatic biopsy than was rectal lignocaine gel or placebo.

Extracorporeal shock wave therapy in the management of Peyronie's disease: initial experience

OBJECTIVE

To evaluate prospectively the efficacy of extracorporeal shock wave therapy (ESWT) as a conservative treatment for Peyronie's disease.

PATIENTS AND METHODS

After obtaining ethical committee approval, 37 patients with Peyronie's disease were treated using ESWT. Before treatment the degree of angulation was assessed by artificially inducing an erection with a vacuum device. The severity of pain on erection was assessed using a visual analogue scale (0-5). Each patient was treated with a minimum of three sessions of ESWT (3000 shock waves at an energy density of 0.11-0.17 mJ/mm2) at 3-week intervals. The results were analysed using the Wilcoxon signed-rank test.

RESULTS

Of the 37 patients, 34 completed the protocol; the mean (range) duration of the disease was 19.43 (4-60) months and the mean follow-up 7.5 (5-11) months. Almost half (47%) of the patients reported an improvement in angulation, with a mean reduction of 29.3 degrees (10 degrees -60 degrees ) (P < 0.001); 12 of the 20 (60%) patients with pain on erection reported immediate relief, the mean reduction being 2.3 (1-4) on the visual analogue scale (P < 0.001). There was only minimal bruising at the site of treatment and no major side-effects were reported.

CONCLUSION

ESWT is an effective and safe treatment for Peyronie's disease; the long-term follow-up and results are awaited.

Prostatic manipulation has a minimal effect on complexed prostate-specific antigen levels

OBJECTIVE

To assess the effect of prostatic manipulation on complexed prostate-specific antigen (cPSA), as various forms of prostatic manipulation are known to increase the serum free and total PSA level.

PATIENTS AND METHODS

A series of 92 men (58 after prostatic biopsy, 16 after digital rectal examination and 18 after flexible cystoscopy) were assessed. Blood samples were taken from each patient before and 30 min after manipulation. Total and cPSA levels were measured using appropriate assays, respectively.

RESULTS

There was no significant increase in cPSA levels after flexible cystoscopy and digital rectal examination, but prostate biopsy caused a statistically significant although minimal rise in cPSA level. There was no statistically significant increase in cPSA level after prostate biopsy in patients with prostate cancer (P = 0. 35) although there was a statistically significant but minimal rise in cPSA level in patients with benign histology (P < 0.01, mean increase 2.13 ng/mL) compared with that of total PSA, which increased markedly (P < 0.01, mean increase 19.79 ng/mL).

CONCLUSION

Prostatic manipulation has minimal effects on cPSA levels.

A prospective evaluation of scrotal ultrasonography in clinical practice

OBJECTIVES

To prospectively evaluate scrotal ultrasonography (SUS) in patients presenting with scrotal symptoms and to make recommendations about use of SUS in clinical practice.

PATIENTS AND METHODS

Forty-eight men with scrotal symptoms were examined by a urologist and independently underwent SUS by one radiologist with no knowledge of the clinical diagnosis. The clinical and SUS diagnoses were compared and the effect on subsequent management recorded.

RESULTS

The clinical and SUS diagnoses agreed in 35 men (73%) although SUS provided an additional diagnosis in half of these men. The SUS diagnosis differed in 13 men (27%) although the management was altered in only four patients.

CONCLUSION

The clinical diagnosis is correct in most men with scrotal symptoms; the routine use of SUS is inappropriate and should be reserved for specific indications.

The short-term prostate-specific antigen velocity before biopsy can be used to predict prostatic histology

OBJECTIVES

To evaluate whether the short-term prostate-specific antigen (PSA) velocity before biopsy can be used to predict prostatic histology, and to assess the role of a second PSA measurement before prostate biopsy.

PATIENTS AND METHODS

The study comprised 197 patients who were referred for transrectal ultrasonography (TRUS) and prostate biopsy. The PSA level was initially measured at the first outpatient assessment; patients with a serum PSA level of < 4 ng/mL and > 50 ng/mL were excluded. Blood samples were taken just before prostate biopsy for the second PSA measurement. The mean interval between the measurements was 2.2 months. The short-term PSA velocity was calculated and correlations between this variable and age, prostate volume and initial PSA levels determined.

RESULTS

There was a statistically significant difference between the short-term PSA velocity of patients with benign prostate histology and those with prostate cancer (P < 0.05). The short-term PSA velocity alone had the same diagnostic accuracy as the serum PSA level (area under the receiver-operating characteristic curve 0.612). There was only a weak correlation between the short-term PSA velocity and prostate volume. However, there was no correlation with age and initial PSA level in patients with benign histology. The second PSA measurement had higher specificity without losing sensitivity.

CONCLUSION

The short-term PSA velocity estimated before biopsy can be used to predict prostatic histology. By measuring serum PSA 2 months after the first in patients with serum PSA level of 4-10 ng/mL, the number of negative biopsies can be reduced by 17%.

Free prostate-specific antigen 'in the field': a useful adjunct to standard clinical practice

OBJECTIVES

To determine the clinical utility of the ratio of free to total prostate-specific antigen (f/tPSA), which may improve the discrimination of PSA testing in the assessment of patients with prostatic disease, in a busy clinical practice.

PATIENTS AND METHODS

A series of 198 men undergoing transrectal ultrasonography (TRUS)-guided biopsy, because of a high total PSA level or an abnormal digital rectal examination or both, had blood samples taken for the assessment of both free and total PSA before any form of prostatic manipulation. The histological findings were compared with tPSA, fPSA and f/tPSA, evaluating three different thresholds of f/tPSA.

RESULTS

PSA levels, PSA density and fPSA density differed significantly between those with benign histology and neoplasia. The f/tPSA only differed significantly in men with a PSA level of 10. 1-15 ng/mL. The f/tPSA threshold of 0.25 was the most useful clinically, with a negative predictive value for prostate cancer of 91%. Using this threshold would reduce the negative biopsy rate by 30%.

CONCLUSION

The f/tPSA is of clinical value in reducing the negative biopsy rate and in the management of patients with a high PSA level and previous negative biopsies.

Outpatient flexible cystoscope-assisted insertion of ureteric catheters and ureteric stents

OBJECTIVE

To examine the feasibility of inserting ureteric catheters (before retrograde ureterography) and JJ ureteric stents (both traditionally performed under general anaesthesia on inpatients) using local anaesthesia in an outpatient setting and with no patient selection bias, thus providing procedures to ease the demand on inpatient lists.

PATIENTS AND METHODS

All patients presenting with an appropriate clinical indication for either of the procedures underwent insertion during a scheduled flexible cystoscopy session in the outpatient department; information was collected on a standard proforma. Antibiotic prophylaxis and a nonsteroidal analgesic were administered 30 min before the procedure.

RESULTS

To date, 20 patients (seven men, age range 32-74 years, and 13 women, age range 23-86 years) have undergone one of the two procedures. Fourteen patients had attempted retrograde catheter insertion, with success in 12, and six other patients underwent attempted JJ ureteric stent insertion, with success in five. The three failures were caused by an inability to see the relevant ureteric orifice. The mean duration of each procedure was 11 min; 14 of the 17 patients who had a successful procedure had no significant pain or discomfort, while the remaining three experienced significant pain and discomfort. There were no infective complications.

CONCLUSION

These two procedures are suitable for the outpatient/day-case situation, and are well tolerated and accepted by most patients.

The effect of digital rectal examination, flexible cystoscopy and prostatic biopsy on free and total prostate specific antigen, and the free-to-total prostate specific antigen ratio in clinical practice

PURPOSE

We evaluated the effects of common urological maneuvers on serum free prostate specific antigen (PSA) and established guidelines for clinical practice.

MATERIALS AND METHODS

Total and free PSA, and free-to-total PSA ratio were determined in 82 men with lower urinary tract symptoms before and 30 minutes after 3 different prostatic manipulations: 1) digital rectal examination (36 cases), 2) flexible cystoscopy (26) and 3) transrectal ultrasound guided prostatic biopsy (20). PSA forms were measured with Hybritech Tandem-R assays.

RESULTS

Cystoscopy had no effect on total PSA, while digital rectal examination had a slight, statistically significantly positive effect and biopsy uniformly increased total PSA (geometric mean ratio 2.43, t = 5.08, p <0.001). Free PSA was increased by digital rectal examination (geometric mean ratio 1.67, t = 4.25, p <0.001), prostatic biopsy (geometric mean ratio 4.80, t = 7.48, p <0.001) and cystoscopy (geometric mean ratio 1.21, t = 2.51, p = 0.019). There was a significant increase in free-to-total PSA ratio after each maneuver. The rate of change in free PSA and free-to-total PSA ratio after biopsy differed between patients with benign and malignant histological findings.

CONCLUSIONS

Free PSA and free-to-total PSA ratios are altered by all forms of prostatic manipulation. The PSA response to manipulation may be different in patients with prostatic malignancy. Phlebotomy must precede digital rectal examination in the clinical and research setting to avoid misleading results.

Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound

OBJECTIVES

To correlate prostate size estimates performed by single or multiple examiners through digital rectal examination (DRE) with volume measured by transrectal ultrasound (TRUS) and to propose measures for predicting prostate volume using DRE estimates in clinical settings.

METHODS

Data from four sources were analyzed: (1) the Olmsted County community study of 397 patients examined by a single urology nurse, with TRUS measurements done by multiple examiners; (2) a community study in Stirling, Scotland, involving 480 patients with DRE and TRUS performed by one urologist; (3) baseline data from the Veterans Affairs Cooperative Study No. 359 in 1222 patients with DRE and TRUS measurements by multiple personnel at 31 centers; and (4) a clinical series of 100 men with DRE and TRUS by a single urologist.

RESULTS

DRE estimates and TRUS volumes were significantly correlated (r = 0.4 to 0.9), but prostate size was underestimated by 25% to 55% for men with a prostate volume over 40 mL, depending on the study, with greater variability for studies involving multiple examiners. In one study that assessed prostate dimensions by DRE, posterior surface area (SA) correlated with overall TRUS volume (r = 0.4). According to receiver operating characteristic curves, SA showed a 70% and 76% chance of correctly identifying men with prostate volume greater than 30 or 40 mL, respectively; those with larger prostates were best distinguished by SA greater than 7 cm2 (sensitivity greater than 0.74, specificity greater than 0.50).

CONCLUSIONS

DRE underestimates prostate size, particularly if TRUS volume is greater than 30 mL. However, DRE estimates may help identify prostates likely to be larger than certain cutpoints by TRUS. Posterior SA may be useful as a preliminary assessment when prostate size is an important predictor of therapeutic response.

Open versus closed epididymal sperm retrieval in men with secondarily obstructed vasal systems--a preliminary report

OBJECTIVE

To evaluate and compare sperm quality and suitability for intracytoplasmic sperm injection (ICSI) from open and percutaneous epididymal aspiration in men with obstructive azoospermia, and to determine the relevance of epididymal morphology.

PATIENTS AND METHODS

A series of 20 men undergoing vasectomy reversal were evaluated by percutaneous (PESA) and open epididymal sperm aspiration (MESA) before undergoing surgery for reversal. Two samples were taken with PESA, one with the needle in situ (PESA1) and the second while withdrawing the needle (PESA2). Epididymal morphology was graded as normal, distended and grossly distended. Five men undergoing vasectomy served as a control, nonobstructed group for percutaneous aspiration. Analysis of the aspirates was performed immediately after operation with no knowledge of the treatment, and aspiration was considered successful if sperm suitable for ICSI were retrieved.

RESULTS

In the obstructed group, 15 of 20 men had successful PESA and 13 of these also had successful MESA. PESA was successful bilaterally eight times compared with MESA on five occasions; two men with successful PESA had no success with MESA. PESA2 was five times more successful than PESA1. Only one PESA in the non-obstructed group was suitable for ICSI. PESA was successful in 21 of 25 distended or grossly distended epididymi compared with only three of 21 non-distended systems.

CONCLUSION

PESA is a viable alternative to MESA in patients with obstructive azoospermia, particularly when associated with clinically distended epididymi.

Reproducibility and observer variability of transrectal ultrasound measurements of prostatic volume

Transrectal ultrasound (TRUS) is an established investigation in benign and malignant prostatic disease though the level of reproducibility of TRUS volume measurements is not known. A group of observers in the UK and the USA who were participating in linked prospective studies of benign prostatic hyperplasia each carried out measurements during real-time scanning and on a series of static TRUS images. Results demonstrated good reproducibility for measurements of antero-posterior, transverse, and longitudinal dimensions of the prostate by an experienced UK urologist; only a minor degree of interobserver variation occurred in measurements made between experienced UK and USA observers. Using static images, USA observers obtained results that were in good agreement, whereas the UK observers, only two of whom used TRUS regularly, were in poor agreement with each other. This study demonstrates a high level of reproducibility for TRUS volume measurements performed by experienced observers.

Predicted and actual change in serum PSA following prostatectomy for BPH

OBJECTIVE

To determine the relationship between prostatic adenoma volume and serum prostate-specific antigen (PSA) levels in patients with benign prostatic hyperplasia (BPH), and to compare the predicted change in serum PSA following prostatectomy with the actual change observed.

METHODS

Transrectal ultrasound (TRUS) estimation of prostatic adenoma (transition zone) and total gland volumes were calculated in 96 patients prior to prostatectomy. BPH was confirmed histologically following transurethral prostatectomy (in 86) and open prostatectomy (in 10). Serum PSA was measured preoperatively in all patients and post-operatively in 87 patients.

RESULTS

Correlation coefficients of 0.607 and 0.614 were observed between PSA and adenoma and total gland volumes, respectively. The geometric mean ratio of PSA to adenoma volume was 0.120 micrograms/L/cc with 95% CI (0.104, 0.139) and to total gland volume was 0.068 micrograms/L/cc with 95% CI (0.058, 0.078). TRUS-determined adenoma and total gland volumes correlated well (r = 0.915), as did TRUS-determined adenoma volume and resected weight (r = 0.878). The mean ratio of change in PSA to resected weight was -0.096 micrograms/L/g with 95% CI (-0.128, -0.064). Neither total gland volume nor operation type affected the relationship between change in serum PSA and resected weight.

CONCLUSIONS

The adenoma should be the main determinant of serum PSA levels in patients with BPH. TRUS adenoma volume measurement is therefore the most appropriate preoperative measure when one is interpreting elevated levels of serum PSA in men thought clinically to have BPH.

Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men

To assess the importance of benign prostatic hyperplasia on activities of daily living, a cross-sectional survey of 1627 men aged 40-79 years (representing a 65% response rate) registered with two health centres in central Scotland was carried out, using a urinary symptom questionnaire and uroflowmetry to identify men more likely to have benign prostatic hyperplasia. The condition was defined as a prostate gland of more than 20 g in the presence of symptoms of urinary dysfunction and/or a peak flow rate of less than 15 ml s-1, without evidence of malignancy. Transrectal ultrasonography was used to measure the volume (and by inference weight) of prostate glands. A total of 410 men satisfied the criteria for benign prostatic hyperplasia. Overall, 51% of men with benign prostatic hyperplasia reported interference with at least one of a number of selected activities of daily living as a result of urinary dysfunction, compared with 28% of men who did not have this condition. In 17% of men of working age (40-64 years) with benign prostatic hyperplasia, this interference occurred most or all of the time for at least one activity of daily living compared with only 3% of men in the same age group who did not have this condition. If the criteria of unmet need for treatment of benign prostatic hyperplasia constitutes interference by urinary dysfunction most or all of the time in at least one activity of daily living, then the findings of this survey suggest that a substantial number of middle aged and elderly men living in the United Kingdom may be in need of assessment and treatment for this condition.

Ultrasonically determined patterns of enlargement in benign prostatic hyperplasia

A series of 430 men aged 40 to 79 years underwent transrectal ultrasonography (TRUS) as part of a community survey of benign prostatic hyperplasia (BPH). We describe a reproducible method of prostate volume estimation and discuss the implications of prostate dimension changes in BPH. The mean prostate and adenoma volumes for the group were 32 ml (SD 14) and 15 ml (SD 11) respectively. The antero-posterior dimension of the prostate (APD) had the strongest correlation with gland volume compared with the transverse dimension (TD) and length (L). The mean ratio of adenoma volume to prostate volume was 0.45 (SD 0.13) and this increased with increasing gland volume. There was a modest correlation between the ratio and prostate volume. BPH is characterised by a proportionally greater increase in the APD compared with L and TD and by an increasing adenoma/prostate ratio. TRUS is useful in assessing the type and extent of adenoma and prostate enlargement in BPH.