Candida nivariensis: Identification strategy in mycological laboratories

Candida nivariensis is a cryptic fungal species classified within the Candida glabrata complex. It was described for the first time in 2005 by the means of DNA sequencing. We report a rare case of C. nivariensis deep-seated infection occurring in a 77-year-old man hospitalized for cysto-prostatectomy. Phenotypic testing based on the direct examination and the macroscopic features of the in vitro culture initially suggested C. glabrata species, while MALDI-TOF mass spectrometry enables correct identification. The isolate was found resistant to fluconazole, like in almost 20% of the reported cases. Herein, we present our practical strategy to reliably characterize this rare cryptic species. To date, MALDI-TOF mass spectrometry-based analysis showed very good results for such a purpose.

[Evaluation of the impact of CTMH guidelines on the management of benign prostatic hyperplasia]

INTRODUCTION

The French guidelines on the management of benign prostatic hyperplasia (BPH) have been published in 2012 by the LUTS committee of the French Urological Association. The aim of this study was to evaluate the impact of these guidelines on the BPH management by French urologists.

MATERIAL AND METHODS

A questionnaire has been distributed by email to 1141 urologists members of the French Association of Urologists in November 2013.

RESULTS

We collected 222 responses (response rate: 19%). The guidelines have been read by 73% of the urologists. The guidelines were followed most of the time by 76% of them, 11% followed them systematically and 4.5% did not follow them. The new terminology was used by 28 to 52% according to the items. The symptoms were evaluated by the IPSS score (33%), by interrogatory alone (64%) or by neither of them (3%). Prostate volume was not systematically taken for account in the treatment strategy by 57% of the urologists. Sexual function was assessed systematically by 28% of the urologists, 11% used a questionnaire (IIEF: 92%). PSA was tested respectively by 70 and 51% of the urologists at the initial evaluation and the follow-up. After introduction of a monotherapy, 56% of the urologists evaluated the efficacy at 3 months.

CONCLUSION

The French guidelines for the management of benign prostatic hyperplasia (BPH) by the LUTS committee of the French Urological Association were well known and used by French urologists. Some improvements can be expected for the use of the IPSS score, the evaluation of the sexual function, and the use of the new terminology.

LEVEL OF EVIDENCE

4.

[Seminal vesicle biopsies: Interest in the prostate cancer staging before radiation therapy or brachytherapy]

OBJECTIVE

Seminal vesicle biopsies (SVB) in the staging of prostate cancer are controversial. Our main objective was to assess their contribution before radiation therapy or brachytherapy. Our secondary objective was to compare pathologic findings of the SVB to the magnetic resonance imaging's (MRI) results.

PATIENTS AND METHODS

From 2000 to 2008, 135 men (median age: 70 years) with prostate cancer (cT1a to cT3) underwent SVB right and left. The median PSA was 12 ng/ml. The median Gleason score was 7. Forty-one patients had an endorectal MRI. The median follow-up was 47 months.

RESULTS

Seminal vesicle involvement was found in 10% of patients. In 9.2% of cases, the biopsy was not contributive. The risk of invasion was significantly associated with the stage T3, the Gleason score up to 7 and the percentage of prostate positive biopsies. A MRI was performed in 41 cases: the correlation between MRI and SVB for the invasion of seminal vesicle was significant but moderate (kappa=0.38). The complications rate of SVB was 10%.

CONCLUSION

SVB were a simple and profitable method. They have provided supplementary information that could improve the staging and that could lead to the make use of an appropriate treatment. This information was comparable to the information provided by MRI. Further studies should establish their role in relation to MRI and in particular confirm the best specificity of the SVB.

[Management of patients under anticoagulants for transurethral resection of the prostate: a multicentric study by the CTMH-AFU]

OBJECTIVE

To determine how are managed patients with anticoagulation treatments who are operated by transuretral resection of the prostate (TURP), and to evaluate the morbidity associated to these treatments.

MATERIALS AND METHODS

This is a retrospective study on 226 patients operated consecutively in six french hospitals between January 2007 and August 2008 by TURP for symptomatic benign prostatic hypertrophy (BPH).

RESULTS

Eighty-three patients (37%) operated by TURP were under anticoagulation treatment before hospitalization. (23 cases under coumarin derivatives, 57 cases under platelet aggregation inhibitors, and three cases under low molecular weight heparin). Management of anticoagulation for the operative period was very heterogenic. Overall, patients under anticoagulation treatment had significantly longer hospitalization period (5.8 versus 4.9 days, p = 0.003) and were more frequently re-hospitalized for hematuria (14.5% versus 1.4%, p < 0.001). Considering early and late morbidity, no significant difference was observed between patients under coumarin derivatives and those under platelet aggregation inhibitors.

CONCLUSIONS

This study assessed the risk of anticoagulants in BPH surgery, and showed the necessity of establishing protocols and recommendations for the management of patients under anticoagulation treatment requiring BPH surgery.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.

MATERIALS AND METHODS

Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.

RESULTS

The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).

CONCLUSIONS

The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE

We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer.

MATERIALS AND METHODS

Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk.

RESULTS

The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92).

CONCLUSIONS

The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

[Standards, options, and recommendation for external radiotherapy of prostatic cancer: evaluation of the effect of dosage]

CONTEXT

The "Standards, Options and Recommendations" (SOR) collaborative project was initiated in 1993 by the Federation of the French Cancer Centres (FNCLCC), with the 20 French Regional Cancer Centres, several French public university and general hospitals, as well as private clinics and medical speciality societies. Its main objective is the development of serviceable clinical practice guidelines in order to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review, followed by critical appraisal by a multidisciplinary group of experts. Draft guidelines are produced, then validated by specialists in cancer care delivery.

OBJECTIVES

Produce clinical practice guidelines for the radiotherapy of prostate cancer using the methodology developed by the Standards, Options and Recommendations project.

METHODS

The FNCLCC and the French Urology Association (AFU) designated the multidisciplinary group of experts. Available data were collected by a search of Medline and lists selected by experts in the group. A first draft of the guidelines was written, they validated by independent reviewers.

RESULTS

The main recommendations are: 1/ a minimal dose of 70 Gy must be used, whatever the prognostic factors; 2/ it appeared that patients with favourable prognostic indicators (stage T1-2, PSA < or = 10 micrograms/L and Gleason score < or = 6) do not benefit from a dose escalation effect for doses over 70-74 Gy; 3/ patients with intermediate prognosis are the ones who benefit most from the dose escalation effect over 74 Gy, provided they receive exclusive radiation therapy; 4/ whenever possible, patients should be included in controlled trials designed to assess the effects of dose escalation and hormonotherapy.

Prevalence and risk factors of urinary incontinence in young and middle-aged women

Objective To assess the prevalence of and risk factors for urinary incontinence (UI) in young and middle-aged women. Subjects and methods During 1998 the prevalence of overall, stress, urge and mixed UI was assessed in women working in a French academic hospital. Women (2800) received a questionnaire at the same time as their yearly interview with a staff physician in occupational medicine. The usual risk factors for constitutional events, i.e. increasing age, obesity (defined as a body mass index of > or = 25), obstetric events (pregnancy, previous Caesarean delivery, previous vaginal delivery, postpartum incontinence) and gynaecological events (hysterectomy) were evaluated. Results Of the 1700 women (mean age 40.0 years) who returned the questionnaire, 467 (27.5%, 95% confidence interval, CI, 25.4-29.7) reported UI, comprising 210 (12.4%, 10.8-14.0) with stress UI, 28 (1.6%, 1.1-2.4) with urge UI and 229 (13.5%, 11.9-15.2) with mixed UI. Thirty-eight women (8.1%) had frequent urinary leakage, comprising one (0.5%), four (14.3%) and 33 (14.4%) with stress, urge and mixed UI. The prevalence of UI increased significantly with age > or = 40 years, with a relative risk (95% CI) of 2.16 (1.86-2.57), and with pregnancy (2.22, 1.71-2.87), previous vaginal delivery (2.15, 1.72-2.69), postpartum incontinence (2.57, 2.22-2.97), and hysterectomy (1.52, 1.11-2.08). Obesity (1.14, 0.99-1.32) and previous Caesarean delivery (2.15, 1.72-2.69) did not significantly increase the risk of UI. The risk factors for stress UI were age > or = 40 years, pregnancy, previous vaginal delivery, postpartum incontinence and hysterectomy, but there was no relationship between stress UI and obesity or previous Caesarean delivery. Conclusion There was a high prevalence of UI among young adult and middle-aged women hospital workers who had easy access to medical resources. Gynaecological and obstetric events (pregnancy, particularly previous vaginal delivery and hysterectomy) were the most prominent risk factors, especially for stress UI.

[Standards, Options, and Recommendations for brachytherapy in patients with prostate cancer: efficacy and toxicity]

CONTEXT

The "Standards, Options and Recommendations" (SOR) collaborative project was initiated in 1993 by the Federation of the French Cancer Centres (FNCLCC), with the 20 French Regional Cancer Centres, several French public university and general hospitals, as well as private clinics and medical specialty societies. Its main objective is the development of serviceable clinical practice guidelines in order to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review, followed by a critical appraisal by a multidisciplinary group of experts. Draft guidelines are produced, then validated by specialists in cancer care delivery.

OBJECTIVES

Produce clinical practice guidelines for the brachytherapy of prostate cancer using the methodology developed by the Standards, Options and Recommendations project.

METHODS

The FNCLCC and the French Urology Association (AFU) first designated the multidisciplinary group of experts. Available data were collected by a search of Medline and lists selected by experts in the group. A first draft of the guidelines was written, they validated by independent reviewers.

RESULTS

The main recommendations are: 1/Brachytherapy with permanent seeds alone is a possible curative treatment for prostate cancer patients with the following prognosis factors: tumour stage T1 or T2a (TNM 1992), Gleason score < or = 6 and PSA < 10 micrograms/L. 2/Combined treatment with brachytherapy and hormonal therapy could be more efficient than brachytherapy alone for prostate cancer patients with Gleason score > 7 and/or PSA > 10.3/Combination of brachytherapy and external beam radiation therapy can be proposed to prostate cancer patients with intermediate prognosis. 4/Before and after seed implantation, risks of infection must be prevented by appropriate antibiotic therapy (recommendation). 5/Brachytherapy must not be performed within 2 months of transurethral prostate resection. 6/The height of the urethra receiving more than 200% of the prescribed dose must be reported. The portion of the rectum receiving 100 and 120% of the prescribed dose must be limited to 10 and 5 mm length, respectively.

Patterns of spread of adenocarcinoma in the prostate as related to cancer volume

BACKGROUND

Peripheral zone (PZ) and transition zone (TZ) cancers of the prostate remain confined to their zone of origin under 4 cc volume, with progressive molding to TZ boundary. In PZ cancer, growth in perineural spaces over 4 cc volume directs cancer toward the base, around subcapsular nerve trunks, and often transcapsular. This tendency to stereotyped patterns of cancer spread in the prostate is investigated systematically here for the first time.

METHODS

Cancers in 571 radical prostatectomy specimens were sorted by zone of origin and tumor volume. A traced map of each cancer at 3 mm transverse intervals was assessed for location, contour, selected linear measures and the "transverse (largest) reference plane".

RESULTS

Spread along prostate capsule characterized all but the smallest PZ cancers and was most extensive transversely. By 4 cc volume, most PZ cancers' transverse reference plane filled one side of PZ. Above 4 cc, bilateral spread, TZ invasion, and nodularity progressively increased, but dominant growth was toward the base along nerves to the superior pedicle; here capsule penetration was most common. TZ cancers arose mainly in anterior-mid TZ, invading anterior fibromuscular stroma (AFM) while small. AFM was massively invaded in many large tumors. Larger TZ cancers (> 4 cc) invaded anterolateral PZ but seldom penetrated posterior PZ.

CONCLUSIONS

Patterns and extent of spread of carcinoma in the prostate are stereotyped following a few principles regarding stromal interactions. Using these, sequential maps were presented of evolving prostate cancer contours at consecutive increasing volumes.

Intestinal perforation as a complication of tension-free vaginal tape procedure for urinary incontinence

OBJECTIVES

To report and prevent a serious complication of tension-free vaginal tape (TVT) procedure.

CASE REPORT

One day after a TVT procedure, an emergency CT scan showed adhesion of intestinal loops with a pneumoperitoneum. The patient had previously had intra- and retroperitoneal surgery with a sacral cervicopexy and a Burch colposuspension.

CONCLUSION

In such a case of previous surgery, a CT scan may be useful before a TVT procedure.

[Ureteral compression by mesenteric desmoid tumor. Report of 2 cases]

The authors report two cases of abdominal fibromatosis corresponding to Gardner's syndrome, causing hydronephrosis by extrinsic ureteric compression in young men in whom any form of surgical resection would have been in vain. These cases of ureteric compression were treated endoscopically by placement of a double J ureteric stent associated with treatment by tamoxifen in one case and sulindac in the other, with apparent stabilization of the disease. The two patients are regularly followed in the department with ureteric stent replacement two to three times a year.

[Adverse effects of glycolic irrigation solutions]

The aim of this study was to evaluate the frequency and the gravity of Trans Urethral Resection of the Prostate Syndrome or 'TURP Syndrome,' which occurs when irrigating fluids containing 1.5 per cent glycocolle are used. All the adverse effects that occurred with 5 products containing 1.5 per cent glycocolle which were notified to the pharmacovigilance structures in France were reviewed. The adverse effects notified comprised 24 cases of TURP Syndrome and 5 of renal failure. TURP Syndrome consisted of neurological signs (92 per cent); cardiovascular signs (54 per cent); visual disturbance (42 per cent) and digestive signs (25 per cent). Hyponatraemia occurred in all patients (mean 113 +/- 6 mmol.l-1) and 25 per cent of patients died. In 27 per cent of cases TURP Syndrome occurred when glycocolle was in contravention of AMM guidelines. The Drugs Agency has requested that modification be included in the Vidal pharmacopoeia (warnings and adverse reactions) and on glycocolle bags and that surgeons and anaesthetists be informed.

[Classification and treatment of ureteroceles in the adult]

Ureterocele or congenital pseudocystic dilatation of the terminal portion of the ureter due to persistence of Chwalla's membrane is frequent in female adults (17-35%) in its orthotopic form. It expands the short submucosal segment of the normally situated ureter and may be intravesical or extravesical. The diagnosis is primarily radiological based on intravenous urography (IVU) and endoscopy (urethrocystoscopy). Treatment depends on the site of the ureterocele, the clinical context, associated anomalies and especially the dimensions. Endoscopic treatment has numerous advantages and deserved to be more widely used.

[Nephrectomy for cancer in pregnant women. Apropos of a case]

We report on the case of a young pregnant woman who had a malignant tumor of the kidney. The pregnancy did not change the gold standard therapy: radical nephrectomy. Because of the pregnancy the preoperative staging consisted of an abdominal ultrasound and a magnetic resonance imaging for the local extension, and of a chest X-ray looking for pulmonary metastases. According to the literature pregnancy, a situation of immune depression, does not increase the prevalence of malignant neoplasms.

[Screening of cancer of the prostate (IV). Economic approach: the costs of screening tests and treatment. Members of the Sub-Committee of the Prostate of CCAFU]

OBJECTIVES

To estimate the unit and global costs of prostatic cancer screening and the resulting treatments, based on a theoretical screening protocol and the epidemiological data available in France.

METHODS

The screening protocol consisted of digital rectal examination (DRE) performed by the general practitioner and serum prostate specific antigen (PSA) assay, with confirmation of the diagnosis by systematized ultrasound-guided biopsies performed by a specialist. Costs were calculated on the basis of the French National Health rating. Treatment costs were estimated on the basis of real public and private establishment case files. Extrapolations to the general population were based on two estimations of the screening yield.

RESULTS

The theoretical cost of screening was estimated to be 501 French Francs (FF) per person screened and 16,700 or 91,000 FF per cancer detected, depending on the detection rate adopted. The mean cost of curative treatment was estimated to be 44,000 FF per cancer. The theoretical global cost of screening and treatment was estimated to be between 4 and more than 10 billion French Francs.

CONCLUSION

Unit costs per individual of screening and treatment of prostatic cancer may appear acceptable. The biases of economic calculations related to extrapolations to the general population and uncertainties concerning the public health benefits of organized screening compared to the current situation of individual screening explain the current predominant attitude of non-recommendation of organized screening.

Eutectic mixture of local anesthetics in adult urology patients: an observational trial

BACKGROUND AND OBJECTIVES

The effectiveness of EMLA eutectic mixture of local anesthetics, (ASTRA Co, France) cream in minor surgery on the penis and its acceptability in unpremedicated outpatients were assessed.

METHODS

EMLA cream was applied 1 hour before surgery (fremulum plasty, circumcision or dorsal section for phimosis, and condyloma accuminatum) in addition to a subcutaneous infiltration of lidocaine 1%, just before incision in cases of circumcision. Verbal Rating Scale (VSR) was assessed during the surgery and the acceptance 15 days later by a questionnaire.

RESULTS

Thirty-two patients included. In all of the cases, the application of EMLA cream was sufficient, with the exception of one (fremulum plasty). General anesthesia was used for this patient unable to tolerate the proprioceptive sensations (VRS = 0). In cases of circumcision, the subcutaneous infiltration was not experienced as painful. Eighty-eight percent of patients who answered the questionnaire confirmed that if they had to be reoperated on, they would opt for this technique of anesthesia.

CONCLUSION

EMLA cream is effective in minor penile surgery in adult patients, and it is associated with subcutaneous infiltration of local anesthetic in the case of circumcision.

[Discovery of a renal chromophobe cell carcinoma in a pregnant woman. Apropos of a case]

We report the case of a young pregnant woman with a malignant tumour of the kidney suggestive of oncocytoma. Because of the pregnancy, preoperative staging consisted of abdominal ultrasound and magnetic resonance imaging. Caesarean section was performed. Several days later, surgical exploration of the kidney was performed with tumourectomy and frozen section analysis: radical nephrectomy was finally performed. The definitive histology was chromophobe renal cell carcinoma. This is a rare tumour of the kidney, with its own characteristics allowing histopathological diagnosis and with a better prognosis than renal cell carcinoma. In the literature, pregnancy, a situation of immune depression, does not increase the prevalence of malignant neoplasms.

[Prostate cancer screening (III): risk factors, natural history, course without treatment. Characteristics of detected cancers]

The Oncology Committee of the Association Française d'Urologie has up-dated the knowledge concerning prostatic cancer screening since the 1989 Consensus Conference. The results are published in the form of a series of articles referring to the criteria used as prerequisites for cancer screening programmes. This article reports the data of the literature concerning risk factors, natural history, course without treatment and histological characteristics of the cancer detected. 1) Certain populations have an increased risk due to genetic factors. A family history (first degree relative) is associated with a 2- to 3-fold higher risk of prostatic cancer. This familial aggregation can be used to define a high-risk group constituting a primary target for screening. 2) The natural history of the disease, especially the progression from the asymptomatic stage to the clinical stage and the natural history of the disease at the clinical stage are now sufficiently well known. The concept of latent cancer has not been confirmed as the disease inevitably progresses. Cancers of insignificant volume, less than 0.5 cc (discovered at autopsy) are classically distinguished from cancers of significant volume, greater than 0.5 cc, but asymptomatic (risk of progression with mortality within 15 years), and local and/or metastatic symptomatic cancers. The histological prevalence of prostatic cancer is 43% in a group of men with a mean age of 64 years and increases with age. 92% of histological cancers have a volume less than 0.5 cc. It takes an estimated 12 years (3 doubling times) for a 0.5 cc cancer to reach a volume of 4 cc, the volume beyond which there is a risk of distant metastases. In the absence of curative treatment, a cancer diagnosed at the localized stage before the age of 65 years is associated with a specific survival of less than 30%. The median survival of metastatic prostatic cancer is 2 to 3 years. 3) The disease can be detected at an early stage. Cancers diagnosed by an isolated elevation of PSA in a screening setting have a significant volume in more than 3 out of 4 cases, can be entirely removed by prostatectomy in more than 3 out of 4 cases and have a less advanced pathological stage than cancers diagnosed on the basis of classical criteria.

[Diagnosis of cancer of the prostate (I): Advancements in knowledge and practice since the consensus conference of 1989. The "Cancer of the Prostate" subcommittee of the Committee of Oncology of the French Association of Urology]

The prostatic cancer screening policy in France is defined by recommendations established at the 1989 consensus conference. Mass or individual screening by serum specific prostatic antigen (PSA) assay is not recommended. The Oncology Committee of the Association Française d'Urologie has up-dated the knowledge concerning prostatic cancer screening since 1989. The results are published in the form of a series of articles referring to the criteria used as prerequisites for cancer screening programmes. This article describes: 1) Current screening and treatment recommendations in France and in other countries. 2) The progress in our understanding of the prognosis, diagnosis and treatment of prostatic cancer, justifying revision of the screening policy. 3) The methodology and results of prospective screening studies and the projections of these results on the basis of the French population. Despite the 1989 recommendations, individual screening by serum PSA assay is widely performed both due to the characteristics of the test (simple blood test, low cost, high positive predictive value) and information of the public by the media concerning the morbidity and mortality related to prostatic cancer. The current data of the literature are unable to define the impact of PSA screening on the morbidity and mortality of prostatic cancer. Randomized prospective studies are currently underway. The absence of proof of a favourable impact of PSA screening is only one of the causes of the controversy concerning this screening technique, as another source of controversy is the magnitude of iatrogenic disorders induced by screening. In patients with raised PSA, the diagnostic examinations (biopsy) and curative treatments (surgery or radiotherapy) proposed are invasive, responsible for considerable morbidity and non-negligible mortality. Finally, the cost of screening remains unknown. Future recommendations must adapt their conclusions to changes in the current situation, in which prostatic cancer is simultaneously considered to be a non-serious disease which does not justify screening and a serious disease, as soon as the diagnosis is made, justifying, for 95% of urologists, an invasive and mutilating treatment in men with a life expectancy of more than 10 years.

[Malignant fibrous histiocytoma of the retroperitoneum]

The authors report two cases of retroperitoneal malignant fibrous histiocytoma which is a rare tumour (200 cases reported in the literature). The clinical and radiological signs are nonspecific and the diagnosis is based on histological examination of the specimen. Surgical resection must be as complete as possible to prevent local recurrence. The efficacy of adjuvant therapy has not been demonstrated due to the low incidence of this tumour.

[Cancer of the prostate. Should men be screened, how to screen, when to screen?]

The individual screening of the general population can only be envisaged after the age of 50 years when the incidence of prostatic cancer increases significantly. Individual screening by PSA in an asymptomatic subject must only be proposed to men likely to benefit from curative treatment, i.e. between the ages of 50 and 70 years, and only after performing digital rectal examination. The combination of these two methods detects 54% of prostatic cancers in men over the age of 50 years. PSA assay can be made more reliable by comparison with age-dependent normal limits, PSA density compared to prostatic volume, rate of progression, and assay of the free and bound fractions.

[The current approach to the management of benign hypertrophy of the prostate]

Epidemiology. The incidence of benign prostatic hyperplasia (BPH) has increased in proportion to the life expectancy and has become the third leading cause of health expenditure in industrialized countries. Eighty per cent of men are treated for benign prostatic hyperplasia during their lifetime. In Europe, the mean age of diagnosis is 65 years. The clinical symptoms are assessed by the IPSS score (International Prostate Symptom Score) and by the maximum flow rate, where frank dysuria is defined as a flow rate of less than 10 ml/sec. Physiology. The prostate contains equal proportions of glandular epithelial structures and fibromuscular connective tissue stroma. The glandular prostate is innervated by cholinergic nerves, while the smooth muscle of the stroma and the urethra are innervated by adrenergic nerves. BPH arises in the transitional zone (fairly glandular). Androgen deprivation (castration, antiandrogens, progestogens, 5-alpha-reductase inhibitors) induces a 30% reduction of the prostatic volume (especially epithelial). BPH could be due to reactivation of the embryonic potential of the stroma. Certain growth factors appear to be involved in BPH. Inflammatory and immunological phenomena may also be involved. Evaluation. Plan of clinical interview, clinical examination and laboratory and radiological data. A 40-year-old man has one chance in 30 of being operated for benign prostatic hyperplasia if he lives to the age of 80. Medical treatments have been developed since 1980 which inhibit the course of BPH and minimize some of the clinical symptoms: plant extracts, alpha-blockers, 5-alpha-reductase inhibitors. Conventional surgical treatments, open prostatectomy and endoscopic resection, have been completed by laser therapy, thermotherapy and cryotherapy.

Cell proliferation in dysplasia of the prostate: analysis by PCNA immunostaining

Patterns of cell proliferation in the prostate were compared between benign epithelium and dysplasia. Proliferating cell nuclear antigen (PCNA) immunostaining was used to quantitate proliferation, and basal cells were tallied separately from secretory cells with the aid of keratin immunostaining. Using a novel technique, absolute cell densities (cells/mm) were determined and used to calculate growth fractions. In benign epithelium, 83% of PCNA+ cells were basal cells, while only 7% of PCNA+ cells in dysplasia were basal cells and there was a clear separation between groups. This dramatic shift of the proliferative compartment to the secretory cells in dysplasia was accompanied only by a moderate increase in overall secretory cell density and moderate reduction in basal cell density, but these ranges overlapped those of benign epithelium. The median PCNA+ secretory cell "growth fraction" was 0.12% in benign epithelium and 1.06% in dysplasia. The findings presented give further support to the concept that dysplasia represents an evolutionary stage in the malignant transformation of prostatic epithelium. The patterns of change in PCNA immunostaining may reflect certain aspects of the biologic nature of malignant transformation.

[The frequency of surgery of benign prostatic hypertrophy]

OBJECTIVES

To calculate the incidence of surgical treatment of benign prostatic hyperplasia (BPH) in two French departments, Indre-et-Loire and C her, in order to deduce the incidence in France.

METHODS

All patients operated for BPH by transurethral resection or transvesical prostatectomy were counted prospectively over a 6-month period by all surgeons of the Indre-et-Loire and Cher departments. Collection of case files was complete and based on BPH resection specimens sent to pathology. 506 patients were included in this survey.

RESULTS

The mean age of the patients was 71.8 years. 78% of patients were operated by a private urologist, and 93% by a specialist urologist. The mean postoperative stay was 7.1 days and varied according to the patient's age, the weight of the prostate and the site of the operation (university hospital, private establishment and general hospital). This study allowed calculation of the annual incidence of surgery for BPH in these 2 departments: 822/100,000 men over the age of 50 years. The maximal incidence was observed during the 7th decade of life: 1,742/100,000. In our study, private urologists operated 76 patients for BPH per year.

CONCLUSION

Extrapolation of these results to the French population indicates an annual incidence of surgery for benign prostatic hyperplasia in France of 776/100,000 men over the age of 50 years. On the basis of this incidence, an estimated 55,000 to 65,000 men are operated for BPH per year in France.

Insufficient dialysis shunts: improved long-term patency rates with close hemodynamic monitoring, repeated percutaneous balloon angioplasty, and stent placement

Over 54 months, 70 short stenoses of 63 shunts (32 Brescia-Cimino fistulas, 31 grafts) in 59 patients necessitated a first percutaneous transluminal angioplasty (PTA). Restenosis led to 63 redilations in 38 lesions. Nine stents were inserted in seven grafts and two proximal veins in seven patients, the indication being that stenosis had recurred twice in 6 months. In three of these stenoses, five delayed intrastent redilations were necessary. Three previously dilated occluded grafts were recovered with local thrombolysis. Morbidity was 4.08%, with one immediate rupture, four delayed pseudoaneurysms (1-28 months), and two periprocedural bacteremias. Half (15 of 29) of graft stenoses and only 14% (four of 27) of Brescia-Cimino fistula stenoses had a mean restenosis interval of less than 6 months. The mean restenosis interval increased from 3.6 months +/- 0.5 (standard deviation) before stent placement to 15.2 months +/- 0.4 after stent placement (P < .001). Insertion of a stent can be advised when stenoses of graft venous anastomoses have recurred twice in less than 6 months. The combination of all interventional radiologic procedures allowed a significant improvement in secondary patency rates after PTA, with 82% at 1 year, 79% at 2 years, and 71% at 3 years.