Validity of three calliper-based transrectal ultrasound methods and digital rectal examination in the estimation of prostate volume and its changes with age: the Krimpen study

BACKGROUND: Prostate volume and its changes are important parameters in studies of the natural history of benign prostatic hyperplasia (BPH), for prediction of treatment effect and the risk of adverse outcomes. The validity of three calliper-based transrectal ultrasound (TRUS) methods and digital rectal examination (DRE) is compared to transrectal planimetric prostate ultrasonometry. METHODS: Data were collected from 1,688 population-based men aged 50-78 years. Measurements included DRE, TRUS using the planimetric method, and three different calliper-based TRUS methods for the estimation of prostate volume. After 2.1 and 4.2 years these measurements were repeated. The agreement between these methods and the ability to discriminate between prostates with volumes above or below a certain cut-off was analyzed. The performance of the different methods to measure changes in prostate volume with age was also studied. RESULTS: All three ultrasound-based methods showed good discrimination compared to the planimetric method. However, the agreement between planimetric volumetry and the other ultrasound methods and DRE is poor. In this study, 22.6% of the men had a real increase in prostate volume after 4.2 years, using the planimetric technique of transrectal ultrasonometry. Only a small percentage of the men (<1.5%) has a real decrease in prostate volume. The alternative measurement methods had a low predictive value for changes in prostate volume with age as measured with the planimetric method. CONCLUSIONS: Calliper-based ultrasonometry and DRE show poor agreement with planimetric volume measurement of the prostate. Changes in prostate volume as determined by the planimetric method are poorly detected by the alternative methods. (c) 2004 Wiley-Liss, Inc.     

Benign prostatic hyperplasia treated by castration or the LH-RH analogue buserelin: a report on 6 cases

This article presents the clinical data of 5 patients treated by castration and 1 patient treated with an LH-RH analogue to relieve chronic urinary retention due to benign prostatic hyperplasia (BPH). Besides the clinical data related to prostatism, prostatic volume was studied in 4 of the 5 patients by means of transrectal ultrasonography. All 5 patients showed a marked decrease of prostatic volume, which averaged 31.4% (range 19-55%) after 2-3 months. This correlated well with a relief of urinary obstruction. In all 5 patients, the indwelling catheters could be removed, symptoms decreased or disappeared and all 5 patients became free of residual urine. LH-RH analogues, because of the reversibility of their effect, may be more acceptable for the treatment of BPH than castration. At this moment however, it remains unknown whether prostatic volume will increase again after cessation of androgen withdrawal.     

Kinetic analysis of focal hypoechoic lesion in the prostate treated by castration

Dynamic changes in the focal hypoehoic lesion (FHL) in the prostate, visualized by transrectal sonography (TRS), were determined in five patients with prostatic cancer (PC) after treatment by castration. In all cases, the volume of FHL, as well as the volume of the whole prostate, decreased exponentially after castration. In four out of five cases, the volume (not including the FHL, which might suggest the volume of the normal tissues) increased slightly in the early postoperative weeks, and decreased thereafter. In the remaining one case, it decreased consecutively. According to the formula established in our previous study, the reduction time (τ) of the volume of the whole prostate and of the volume of the FHL was calculated, indicating that the τ of the FHL was remarkably shorter than that of the volume not indicating the FHL. This evidence suggested that not only the cancerous tissues but also the normal prostatic tissues might reduce in volume after castration. © 1994 Wiley-Liss, Inc.     

Percutaneous transperineal placement of gold 198 seeds for treatment of carcinoma of the prostate

Thirty-one patients have been treated for carcinoma of the prostate with 198Au seeds placed transperineally using transrectal ultrasonic guidance. Twenty patients have been followed postoperatively for periods ranging from 3 to 31 months, with an average follow-up time of 12 months. Cumulative dose of radiation to the prostate calculated by dosimetry was either 9,000 rads or 15,000 rads. Serial transrectal ultrasound examinations performed on these patients showed a decrease in prostate size in all patients within 6 months of treatment, with a statistically significant decrease observed between the third and sixth months. No significant difference in amount or rate of tumor regression was noted when tumor stage and grade were correlated to volume decrease after treatment. Patients who received the larger doses of radiation (15,000 rads) showed a significantly greater rate of decline in prostatic volume than those who received 9,000 rads. Seven patients underwent prostate biopsy between 12 and 18 months after treatment; six biopsies showed residual tumor. Complications after treatment included urinary retention because of prostatic edema (three), radiation urethritis (three), and rectal ulceration (one). Transperineal placement of 198Au is well tolerated and offers an alternative to external beam radiation for treatment of carcinoma of the prostate.     

去势加磷酸雌二醇氮芥治疗前列腺癌(附15例报告)

目的探讨去势加磷酸雌二醇氮芥治疗不宜手术根治的前列腺癌的疗效。方法１９９０年１月～１９９６年５月采用去势加磷酸雌二醇氮芥治疗前列腺癌１５例，其中Ｂ２期５例，Ｃ期７例，Ｄ期３例。１５例均行双侧睾丸切除，术后口服磷酸雌二醇氮芥２８０ｍｇ／次，每日２次。结果随访２０～７９个月，平均４７个月。１３例取得客观疗效，１例肿块无明显缩小者因排尿困难行耻骨上膀胱造瘘，１例死于非瘤疾病。所有病例血常规化验未见骨髓抑制，１０例有乳房胀大。结论去势加磷酸雌二醇氮芥治疗前列腺癌效果较满意，易被患者接受     

The influence of bilateral orchiectomy on volume changes of the prostate in men with advanced prostatic cancer—the predictive value

The changes of prostatic volume were evaluated in 84 men with adenocarcinoma of the prostate treated by bilateral orchiectomy. In every case the greatest volume decrease was observed during the first month after castration. In 56 patients (66.6%), where the response to orchiectomy was better, the recuction of prostatic volume was considerably greater and diminisshed more rapidly than in the remaining 28 patients (33.3%), where the reaction to the treatment was worse.     

Recovery of urinary continence following radical prostatectomy: the impact of prostate volume--analysis of data from the CaPSURE Database

PURPOSE: Improved urinary function following radical prostatectomy due to bladder outlet obstruction from subclinical benign prostatic hyperplasia has been described. We determined if prostate volume determined by preoperative transrectal ultrasound could predict recovery of urinary function and continence following radical prostatectomy. MATERIALS AND METHODS: We identified all 4,984 patients who underwent radical prostatectomy in the CaPSURE national disease registry of men with prostate cancer. Only the 2,097 men who had data available on preoperative prostate volume by transrectal ultrasound, and complete preoperative and postoperative data available on urinary function using the UCLA-PCI were selected for study. Transrectal ultrasound volume was categorized as less than 25, 25 to 50 cc or greater than 50 cc. Univariate and mixed multivariate analyses were performed to determine the association between transrectal ultrasound based prostate volume and continence, as measured by urinary function scores 6 months to 2 years following radical prostatectomy. Analyses were controlled for baseline urinary function as well as other variables, such as body mass index, time of urinary function assessment and patient age at diagnosis. Total and individual item scores on the urinary function subscale were used as outcome variables in separate models. RESULTS: Median transrectal ultrasound prostate volume was 35 cc (IQR 27-47.8). In the ANOVA for mixed models patient age, time of urinary function assessment, body mass index and transrectal ultrasound prostate volume were independent predictors of urinary continence. Patients with prostate volume greater than 50 cc had lower rates of continence, as assessed by urinary function scores 6 months and 1 year after radical prostatectomy, but scores equalized across all volume ranges by 2 years after radical prostatectomy. The individual domains most significantly affected were urinary control (p = 0.02), urine leakage during sexual activity (p = 0.0016) and urine leakage frequency (p = 0.0175). CONCLUSIONS: These data indicate that baseline prostate volume is a predictor of recovery of urinary function after radical prostatectomy. Men with larger volume prostates have lower levels of continence up to 2 years after radical prostatectomy. A potential reason could be subclinical bladder dysfunction related to benign prostatic hyperplasia that manifests after surgery.     

Advantage of systematic random ultrasound-guided biopsies, measurement of serum prostate-specific antigen level and determination of prostate volume in the early diagnosis of prostate cancer.

Two hundred and sixteen patients, presenting with a suspicious digital examination (stage T3 excluded) or a level of prostate-specific antigen (PSA) greater than or equal to 2.5 ng/ml, assessed by radioimmunoassay, underwent a transrectal ultrasound examination. Prostate volume was systematically calculated and correlated to PSA level. Biopsies were performed: (1) on suspicious peripheral hypoechoic areas; ultrasound-guided biopsies; (2) systematically on the 2 prostate lobes, whatever the result of transrectal ultrasound imaging:random systematic ultrasound-guided biopsies. In the 186 patients who had never undergone prostate surgery, ultrasound-guided biopsies showed 42 prostate cancers and random systematic ultrasound-guided biopsies showed 75; 14 of the 76 patients with normal digital rectal examination and transrectal ultrasound imaging had a prostate cancer. In the 30 patients who had previously undergone surgery for benign prostatic hypertrophy, random systematic ultrasound-guided biopsies showed 18 prostate cancers, 13% more than ultrasound-guided biopsies; 75% of patients with a serum PSA greater than 5 ng/ml had a prostate cancer. A very significant correlation was found between PSA level and prostatic volume (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Photoselective vaporization of the prostate: a volume reduction analysis in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia and carcinoma of the prostate

PURPOSE: In this study preoperative and postoperative transrectal ultrasound prostate volume was evaluated in patients undergoing photoselective vaporization of prostate using an 80 W potassium-titanyl-phosphate (KTP) laser (Greenlight PV Laser System, Laserscope, San Jose, California) for obstructive uropathy secondary to benign prostatic hyperplasia or carcinoma of the prostate. MATERIALS AND METHODS: A total of 18 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (8) and carcinoma of the prostate (10) were treated with an 80 W quasicontinuous KTP laser. Preoperative and immediate postoperative treatment prostate volume measurements were recorded by transrectal ultrasound. The end point of treatment was complete vaporization of the obstructive adenoma to the level of the capsular fibers and the creation of an adequate transurethral resection-like prostatic cavity. KTP/532 laser energy was delivered by a side firing glass fiber through a 27Fr continuous flow resectoscope. Photoselective vaporization of the prostate using sterile water irrigation was performed with all patients under spinal anesthesia. Mean lasting time +/- SEM was 33.5 +/- 12 minutes (range 11 to 53). RESULTS: Mean preoperative prostate volume +/- SEM was 53.2 +/- 24.7 ml (range 23.6 to 110), while mean postoperative prostate volume was decreased to 26.2 +/- 14.8 ml (range 8 to 58) during a mean followup of 2.8 +/- 2.3 months (range 1 to 10), resulting in a 51% mean decrease in prostate volume, as measured by transrectal ultrasound. There was no significant intraoperative bleeding and no change in serum sodium postoperatively. One patient sustained a small capsular perforation with persistent venous bleeding, which could not be controlled with KTP laser. Because of poor vision, the procedure was completed with electroresection. Complications included mild dysuria in 2 patients (11%) and mild hematuria longer than 2 weeks in duration in 4 (22%). CONCLUSIONS: Photoselective prostate vaporization can effectively vaporize obstructive benign and malignant prostatic tissue, leading to a significant decrease in the total volume of the treated prostate (p = 0.000).     

Prognostic significance of prostate specific antigen in endocrine treatment for prostatic cancer.

The prognostic value of prostate specific antigen was evaluated to predict disease progression after endocrine therapy in patients with prostatic cancer. A total of 73 patients was studied (6 with stage B2, 16 with stage C, 9 with stage D1 and 42 with stage D2 disease). Endocrine therapy included bilateral orchiectomy, diethylstilbestrol diphosphate and luteinizing hormone-releasing hormone analogue. Pre-treatment serum prostate specific antigen levels were determined in all patients with an enzyme immunoassay kit. During a followup of 4 to 68 months (average 24 months) clinical disease progression occurred in 24 of the 73 patients. The pre-treatment prostate specific antigen level by itself did not predict disease progression. Changes in prostate specific antigen level with treatment were correlated with the interval to disease progression in the 44 patients who had prostate specific antigen determinations at regular intervals after endocrine therapy and whose initial level was greater than 10 ng./ml. Patients who had a decrease in the prostate specific antigen levels of 80% or more within 1 month after the beginning of therapy survived significantly longer free of disease progression (p less than 0.001). Patients whose prostate specific antigen level remained elevated for more than 3 months had a high risk of disease progression within 2 years. Our study suggests that patients with the more favorable prognosis can be identified early, after 1 to 3 months of endocrine therapy, by the rapid decrease in the prostate specific antigen levels.     

Multicenter, randomized, double-blind, placebo controlled study to investigate the effect of finasteride (MK-906) on stage D prostate cancer.

A total of 28 untreated patients with asymptomatic, stage D prostate cancer was randomized in a double-blinded fashion to receive finasteride (10 mg. per day), a 5 alpha-reductase inhibitor or placebo. Patients were evaluated at 3-week intervals by rectal examination, and serum prostate specific antigen (PSA) and prostatic acid phosphatase (PAP) levels, and at 6-week intervals by bone scan and transrectal ultrasound determinations of prostatic volume. Patients stopped the medication at week 6 at the discretion of the investigator when PSA levels increased from baseline. After 12 weeks all patients were reevaluated. Of the patients 13 received finasteride and 15 received placebo. The 2 groups did not differ statistically with respect to patient age, initial PSA and PAP level, or the extent of metastases on initial bone scan. A statistically significant decrease in the median percentage change from baseline in PSA at weeks 3 and 6 occurred in the finasteride group compared to the placebo group (-22.9% versus -2.9% and -15.1% versus +11.7%, respectively, p less than 0.05). Finasteride had no effect upon PAP, serum testosterone, prostatic volume or appearance of bone scans. A decrease in serum PSA in the finasteride treatment group suggests that finasteride exerts a minor effect in patients with prostate cancer. This effect does not approach that seen with medical or surgical castration yet because of the potency preserving feature and the lack of toxicity finasteride may warrant further study in the treatment of prostate cancer.     

PSA值增高患者前列腺液中白细胞计数分析

目的 分析前列腺特异性抗原（PSA）值增高的患者前列腺液中的白细胞数值.方法 对122例PSA值增高的患者进行前列腺液中的白细胞计数,并分析PSA升高白细胞计数值与患者年龄、PSA、前列腺体积等指标的关系.结果 患者的前列腺液中自细胞密度（平均5.29×10^6/mL）和总数（平均1.58×10^6）均增高,白细胞总数与前列腺体积呈显著性相关,非前列腺癌患者比前列腺癌患者的前列腺体积和白细胞总数显著增高.结论 非前列腺癌患者的PSA值增高可能与前列腺液中的白细胞增高有关.     

Changes in serum prostate-specific antigen following prostatectomy in patients with benign prostate hyperplasia

PURPOSE: To investigate how prostatectomy for patients with benign prostate hyperplasia (BPH) affected the serum prostate-specific antigen (PSA) levels. METHODS: In 193 patients who underwent prostatectomy for BPH, serum PSA levels were measured before and three months after the operation. The total prostate weight measured by transrectal ultrasonography (TRUS) and the weight of the surgical specimen were examined in relation to the pretreatment PSA value and the changes in PSA levels after the operation. RESULTS: The transition zone volume measured by TRUS could well estimate the weight of the surgical specimen in patients who underwent subcapsular prostatectomy and transurethral resection of the prostate. The concentration of preoperative serum PSA showed a significant correlation with the prostatic volume and with the transition zone volume. Removal of 1 g of BPH tissue reduced serum PSA levels by an average of 0.18 ng/mL. The change in serum PSA levels after the prostatectomy correlated with the total prostatic gland volume and with the transition zone volume. CONCLUSIONS: The elevated PSA levels in patients with BPH were caused by the enlargement of the transition zone. After the resection of the adenoma, PSA levels should be expected to decrease to the normal range.     

Transrectal Ultrasonography to Predict the Clinical Outcome of Transurethral Microwave Thermotherapy in Patients with Benign Prostatic Hyperplasia

Background: This study evaluated the long-term efficacy of transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH), and determined whether the indices obtained with transrectal ultrasonography (TRUS) can predict the clinical response to TUMT.
Method: Between November 1991 and June 1992, 43 patients with symptomatic BPH were treated with TUMT using the Prostcare device. The therapy consisted of a 1 -hour treatment under topical anesthesia. The findings of uroflowmetry and AUA symptom score before treatment were compared with those obtained dt each visit after the therapy. As the indices, the transition zone (TZ) volume, transition zone ratio (TZ ratio = TZ volume/total prostate volume), total prostate volume, and presumed circle area ratio (PCAR) were calculated.
Results: There was a significant correlation between pretreatment TZ ratio and residual urine volume ( r = 0.472, P = 0.0022). The efficacy rates calculated by response criteria on the 3 point scale at 2 months, 12 months, and 30 months were 44.2%, 30.2%, and 25%, respectively. The significant prognostic factors that predicted the clinical effect 1 year after treatment were the TZ ratio and intraprostatic temperature. After controlling for the treatment temperature, the multivariate logistic regression model demonstrated that the TZ ratio was the significant predictor ( p = 0.049) of 1 year efficacy of treatment.
Conclusion: The present study showed that the efficacy rate of TUMT at 30 months was 25%, and that TKUS provides a simple parameter, the TZ ratio, which predicts the efficacy of TUMT.     

The continuing importance of transrectal ultrasound identification of prostatic lesions

PURPOSE: In light of a recent tendency toward systematic nontargeted biopsy we reassessed whether identification and biopsy of ultrasonographically suspicious lesions contribute to the detection of prostate cancer. MATERIALS AND METHODS: We reviewed prospectively gathered data on 7,426 transrectal ultrasound directed prostatic biopsies performed at our institution between June 16, 2000 and September 1, 2005. Patients underwent systematic biopsy (6 to 10 cores on initial biopsy and 13 to 15 on rebiopsy) with additional sampling of visible suspicious lesions. The RR for finding cancer in transrectal ultrasound positive and negative patients was calculated for likely independent prognostic variables. RESULTS: A total of 3,828 biopsies (51.5%) were transrectal ultrasound negative and 3,598 (48.5%) were transrectal ultrasound positive. Prostate cancer was detected in 3,258 biopsies (43.9%). For each independent variable the RR for prostate cancer was higher if a sonographic lesion was present. A lesion increased the likelihood of cancer detection (57.8% vs 30.8%, RR 1.8). Biopsies from lesions identified by transrectal ultrasound had a greater median percent of the core involved with cancer (50% vs 10%, p <0.001) and they were more likely to have Gleason score 7 or greater (69.3% vs 28.3%, p <0.001). CONCLUSIONS: Biopsies taken when a prostatic lesion is identified by transrectal ultrasound are almost twice as likely to show cancer than when no lesion is visible. These cancers are of higher grade and volume and, therefore, they are more clinically significant. The search for and targeted biopsy of suspicious lesions seen on transrectal ultrasound remains important for prostate cancer diagnosis.     

Pattern of progression and survival in hormonally treated metastatic prostate cancer

BACKGROUND: Patients with prostate cancer generally respond to androgen ablation therapy, but progression to androgen-independence is frequently observed. To further evaluate disease progression, the pattern of progression and survival in hormonally treated metastatic prostate cancer was examined. METHODS: One hundred and ninety-three patients with untreated metastatic prostate cancer (TxNxM ) who received endocrine therapy between 1986 and 1995 were included in the present study. The pattern of progression was evaluated in these patients. RESULTS: One hundred and eighteen of the 193 patients (61.1%) had disease progression: 33 had local progression, 73 had distant progression and 12 had distant with local progression. Patients with only local progression had a longer interval to disease progression and longer survival than those with distant progression. The interval from disease progression to death in patients with local progression was longer than in those with distant progression. The patients whose prostate-specific antigen (PSA) had not been normalized 3 months after the start of endocrine therapy had a tendency to progression either into the prostate or into distant sites. Patients with extent of disease (EOD) scores of 3 and 4 progress, especially to distant sites, after endocrine treatment. CONCLUSIONS: In untreated metastatic prostate cancer, patients with a poor response of PSA levels and patients with a high volume of bone metastasis (i.e. EOD 3, 4) were in the high-risk group for progression, especially to distant sites. Progression into distant sites was a poor prognostic factor for patients with recurrence to endocrine therapy.     

TRANSURETHRAL MICROWAVE THERMOTHERAPY FOR BENIGN PROSTATIC HYPERPLASIA: CLINICAL OUTCOME AFTER 4 YEARS

Purpose

We describe long-term results of transurethral microwave thermotherapy. We determined pretreatment variables favorable for the outcome.

Materials and Methods

We followed for 4 years 187 patients treated with Prostatron software 2.0.^* Preoperative evaluations consisted of score, cystoscopy, transrectal ultrasonography, urine flow and residual volume measurements. Followup examinations with score and urodynamics were performed for 4 years after transurethral microwave thermotherapy. Kaplan-Meier plots and logistic regression were used for statistical analyses.

Results

A decrease in the number of satisfied patients was noted from 62% at 1 year after transurethral microwave thermotherapy to 23% at 4 years. Initial decrease in score and increase in urine flow were followed by increase in score and decrease in flow at the 4-year followup of the 56 patients who had not received supplementary benign prostatic hyperplasia (BPH) treatment. The Kaplan-Meier analysis estimated the median time for need of supplementary BPH treatment to be 45 months. Pretreatment urine flow greater than 10 ml. per second and an irritative score less than 5 were the only factors related to a favorable outcome. Prostate volume or energy delivered to the prostate did not influence the result.

Conclusions

Four years after transurethral microwave thermotherapy 23% of the initially treated group were satisfied with the result. Two-thirds had received supplementary BPH treatment. Preoperatively less obstructed patients and those with low initial irritative scores responded more favorably to transurethral microwave thermotherapy treatment.     

Effect of the addition of estrogen to medical castration on prostatic size, symptoms, histology and serum prostate specific antigen in 4 men with benign prostatic hypertrophy.

A total of 4 men with benign prostatic hypertrophy who underwent medical castration therapy with a long-acting gonadotropin-releasing hormone agonist (leuprolide) for more than 6 months elected to add an estrogen transdermal patch (0.05 mg. to the skin biweekly) to the leuprolide regimen. The average prostatic size (transrectal ultrasound), serum prostate specific antigen (PSA) levels and symptoms of prostatism were dramatically decreased with leuprolide alone. The addition of estrogen for 6 months did not result in any change in prostate size, symptoms or serum PSA levels over that seen with leuprolide alone. The development of squamous metaplasia was noted in 1 man with leuprolide alone and in 1 man after the addition of estrogen. Immunohistochemical staining with anticytokeratin 903 antibodies reveals that squamous metaplasia appears to arise from prostatic basal cells. We postulate that the target cell for estrogen action in the prostate is the prostatic basal cell. In the absence of androgen the only direct effect of estrogens is the induction of squamous metaplasia.     

Ultrasonically guided 125iodine seed implantation with external radiation in management of localized prostatic carcinoma

Thirty-three patients with localized prostatic carcinoma (16 poorly differentiated) were treated with transperineal 125Iodine seed implantation (160 Gy) guided by transrectal ultrasonography and subsequent external beam irradiation (47.4 Gy). The observation time was six to sixty-eight months with a median follow-up of thirty-five months. Median change in prostatic volume was a reduction of 35 percent. Re-biopsy or transurethral resection of the prostate was performed in 25 patients after one to two years, revealing still malignant histology in 12 (48%). Development of distant metastases occurred in 14 patients (44%), and 8 have died of prostatic cancer. Fourteen patients suffered from late complications of which surgical intervention was indicated in 3 cases.     

Clinical experience of local hyperthermia for benign prostatic hyperplasia]

A total of 20 patients with benign prostatic hyperplasia underwent transrectal local hyperthermia. For heating of the prostate gland, the PROSTATHERMER (Biodan-Medical System, Israel) was used. Patients were treated twice weekly, for 1 hour, with 6 sessions on an outpatient basis. Four of the 20 patients who had acute toxicity such as urethral irritability due to urethral thermoprobe could not tolerate the treatment. In the majority of the patients who were completely treated, a significant decrease in frequency of nocturia, decrease in post-void residual urine capacity and increase in urine flow rate were observed. No significant change in prostate volume was noted. With a mean follow-up of 6 months, only 1 patient required subsequent prostatic resection. These findings indicate that local hyperthermia applied by this method is effective in the treatment of benign prostatic hyperplasia and that improvement of the thermometry system is needed.