Biomedical subjects

B Djavan

Publications and source records attributed to B Djavan.

At least 19 recordsLinked to original sources

PubMed1999

Elastin gene expression in benign prostatic hyperplasia.

BACKGROUND: Benign prostatic hyperplasia (BPH) is mainly a stromal process, showing an increased ratio of stromal to epithelial elements, a collagen type III downregulation, and a collagen types I and IV upregulation. Little is known about elastin gene expression in BPH tissues due to difficulties related to extensive alternative splicing of the elastin gene. Therefore, we analyzed and quantified elastin gene expression in BPH. METHODS: A competitive reverse transcriptase-polymerase chain reaction (competitive RT-PCR) quantitative technique was used, and a quantitative elastin mRNA analysis with normal (n = 10) and BPH (n = 12) tissues was performed with two newly designed elastin primers. Small tissue samples (4-8 mg) were homogenized and sonicated, and cDNA was synthesized from mRNA using a RT reaction. Various target (wild-type) elastin cDNAs with unknown concentrations were competitively coamplified with known serial dilutions of the control mutant template, differing from the target cDNA by a short deletion. Gel fractions and computerized densitometry, were performed and cDNA concentration was calculated by linear regression. RESULTS: The primers identified in our study (BOB-1 and BOB-2) accurately amplified a consistent length of the elastin cDNA, avoiding areas of alternative splicing. The average elastin mRNA concentration in BPH tissues was 53 attomole/mg +/- 11.6 vs. 140.6 attomole/mg +/- 19.6 in normal prostatic tissue (P = 0.019). The variation within every sample was less than 10%. CONCLUSIONS: Our observations suggest a significant downregulation (70%) of the elastin mRNA gene in the transition zone of BPH patients.

Aged↗

PubMed1999

Interrelationships of bladder compliance with age, detrusor instability, and obstruction in elderly men with lower urinary tract symptoms.

Data on the interrelationships of bladder compliance (BC), detrusor instability (DI), and bladder outflow obstruction (BOO) in elderly men with lower urinary tract symptoms (LUTS) are scarce and were therefore assessed in this study. Principle inclusion criteria for this study were men aged > or = 50 years suffering from LUTS as defined by an International Prostate Symptoms Score (IPSS) of > or = 7 and a peak flow rate (Qmax) of < or = 15 ml/sec. Patients with previous surgery of the bladder, prostate, or urethra as well as a pathological neurourological status were excluded from this study. The following parameters were studied in all patients: IPSS, prostate volume calculated by transrectal ultrasonography, free uroflow study, post-void residual volume determined by transurethral catheterization, and a multichannel pressure flow study (pQS). A group of 170 men were included in the analysis. The mean BC in the overall group was 32 +/- 2 ml/cm H2O (mean +/- standard error of the mean [SEM]; range, 4-100 ml/cm H2O). In 36.5% of patients, BC was significantly reduced (< or = 20 ml/cm H2O), and in a further 37.1%, it ranged from 20 to 40 ml/cm H2O. BC decreased statistically significantly (p < 0.05) in patients with advanced age, lower Qmax, higher voiding pressures, and larger prostates. In men with DI (n = 61), mean BC was significantly lower (22 +/- 3 ml/cm H2O) compared to those without (37 +/- 3 ml/cm H2O; p = 0.001; n = 109). Patients with severe BOO as defined by a linear passive urethral resistance relationship of > or = 3 (n = 109), had a significantly lower BC (23 +/- 2 ml/cm H2O) compared to those without or minimal obstruction only (39 +/- 3 ml/cm H2O; p = 0.0002; n = 61). Stepwise logistic regression analysis revealed that DI, a low bladder capacity, and a high maximum detrusor pressure were independent predictors of markedly reduced BC (< 20 ml/cm H2O). BC is decreased in elderly men with high voiding pressures, BOO, and DI. The mechanism leading to the reduction of BC under these circumstances is largely unknown and could result from cytostructural alterations of the detrusor and changes in detrusor innervation.

Aged↗

PubMed1999

Neoadjuvant and adjuvant alpha-blockade improves early results of high-energy transurethral microwave thermotherapy for lower urinary tract symptoms of benign prostatic hyperplasia: a randomized, prospective clinical trial.

OBJECTIVES: Improved long-term results with respect to symptoms, voiding function, and quality of life (QOL) in patients with lower urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH) are achieved with targeted high-energy transurethral microwave thermotherapy (TUMT) compared with alpha-blocker treatment alone. However, maximal improvement after TUMT is not attained until 3 to 6 months after treatment. Measures to provide earlier symptom relief and improved voiding function and QOL would add to the clinical utility of TUMT. The objective of the present study was to determine whether neoadjuvant and adjuvant alpha-blockade is capable of accelerating a post-TUMT decrease in LUTS of patients with BPH. METHODS: In this randomized, prospective study of 81 patients with LUTS of BPH, 41 underwent TUMT with neoadjuvant and adjuvant tamsulosin (0.4 mg daily) treatment, and 40 had TUMT alone. International Prostate Symptom Score (IPSS), peak urinary flow rate (Qmax), and QOL score were determined before treatment and at periodic intervals thereafter up to 12 weeks after TUMT. RESULTS: Mean IPSS values in the TUMT plus tamsulosin group at 2 weeks (14.0, 95% confidence interval [CI] 13.1 to 14.9) and 6 weeks (8.6; 95% CI 7.7 to 9.5) were 15% and 24% lower, respectively, than those at 2 weeks (16.5, 95% CI 15.6 to 17.4) and 6 weeks (11.3, 95% CI 10.4 to 12.2) in the TUMT-alone group (P<0.0005). However, by the final evaluation at 12 weeks, no significant difference between the groups in mean IPSS was evident. A similar temporal pattern of difference between the two study groups was also observed in QOL score. No significant between-group difference in mean Qmax was evident after TUMT. Urinary retention 1 week or more in duration occurred in 5 (12%) of 40 TUMT-alone group patients compared with 1 (2%) of 41 TUMT plus tamsulosin group patients. CONCLUSIONS: Neoadjuvant and adjuvant alpha-blocker treatment results in significantly greater early symptom reduction and QOL score improvement after TUMT, adding to the clinical utility of this minimally invasive treatment modality. In addition, post-TUMT complications such as urinary retention may be reduced.

Adrenergic alpha-Antagonists↗

PubMed1999

Impact of chronic dialysis on serum PSA, free PSA, and free/total PSA ratio: is prostate cancer detection compromised in patients receiving long-term dialysis?

OBJECTIVES: The increased incidence of malignancy (ie, prostate cancer) in patients with end-stage renal failure is well known. However, little is known of the impact of hemodialysis and various membrane types on total and free prostate-specific antigen (PSA). We prospectively studied the impact of high- and low-flux dialysis membranes and kidney function on total PSA (tPSA), free PSA (fPSA), and free/total PSA ratio (f/t PSA). METHODS: A total of 149 men were included. tPSA, fPSA, and f/t PSA were measured before and immediately after dialysis with high-flux (n = 101) and low-flux (n = 48) membranes in the serum and in the dialysis ultrafiltrate. A multivariate analysis of the impact of kidney function and age on the rate of change of all parameters was performed. RESULTS: Overall, a significant decrease of fPSA (from 0.49 +/- 0.3 to 0.35 +/- 0.3 ng/mL, P <0.0001) and f/t PSA (from 45 +/- 19% to 38 +/- 13%, P <0.0001) and a nonsignificant decrease in serum tPSA were observed. However, fPSA (from 0.51 +/- 0.5 to 0.27 +/- 0.3 ng/mL, P <0.0001) and f/t PSA (from 47 +/- 19% to 31 +/- 18%, P <0.0001) decreased significantly in high-flux membranes only. The ultrafiltrate contained 100% fPSA in high-flux membranes and no fPSA in low-flux membranes. Age, serum creatinine, blood urea nitrogen, and dialysis evaluation parameters (Kt/V) had no impact on correlation with changes in tPSA and fPSA. CONCLUSIONS: tPSA molecules do not pass high- and low-flux membranes; fPSA passes high-flux membranes only. The nonsignificant decrease of tPSA is due to adsorption to both dialysis membranes. Although tPSA can safely be used to screen patients on dialysis, independently from the dialysis procedure and membrane, fPSA and f/t PSA are only reliable with low-flux membranes. Finally, we can state that the fPSA is most probably cleared through the kidneys by glomerular filtration.

Adult↗

PubMed1999

Temporary intraurethral prostatic bridge-catheter compared with neoadjuvant and adjuvant alpha-blockade to improve early results of high-energy transurethral microwave thermotherapy.

OBJECTIVES: The maximal effect of transurethral microwave thermotherapy (TUMT) for lower urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH) occurs 3 to 6 months after treatment. In the acute period after TUMT, little change in symptoms, quality of life (QOL), and peak urinary flow rate (Qmax) is observed versus baseline. Some men may also develop acute urinary retention secondary to thermally induced edema. Recent reports suggest that early results of TUMT may be improved with concomitant use of either a temporary intraurethral prostatic bridge-catheter (PBC) or neoadjuvant and adjuvant alpha-blocker therapy. This report compares the results of these two adjunctive modalities directly. METHODS: This nonrandomized retrospective comparison of results in 186 patients with LUTS of BPH is based on findings of three recently reported prospective clinical trials. All patients underwent targeted high-energy TUMT. Ninety-one patients received no further treatment (TUMT alone group), 54 an indwelling PBC for up to 1 month (TUMT + PBC group), and 41 neoadjuvant and adjuvant tamsulosin (0.4 mg daily) treatment (TUMT + tamsulosin group). The International Prostate Symptom Score (IPSS), QOL score, and Qmax were determined at baseline and 2 weeks after TUMT. RESULTS: All three study groups experienced statistically significant improvements in mean IPSS and QOL score at 2 weeks versus baseline (P <0.0005). Nevertheless, the magnitude of improvement was greater in the TUMT + PBC group than the other two groups and greater in the TUMT + tamsulosin group than the TUMT alone group. A high proportion of the TUMT + PBC group (87.8%) attained a 50% or more IPSS improvement, compared with 4.5% of the TUMT alone group and none of the TUMT + tamsulosin group, and a similar pattern of between-group differences was noted with respect to the proportion of patients having 50% or more improvement in QOL score. The TUMT + PBC group was the only group to achieve significant Qmax improvement at 2 weeks compared with baseline. In the TUMT alone group, urinary retention 1 week or longer in duration occurred in 10 (11%) of 91 patients compared with 1 (2.4%) of 41 in the TUMT + tamsulosin group and none in the TUMT + PBC group. Early PBC removal was required in 11% of the TUMT + PBC group as a consequence of urinary retention secondary to clot formation or PBC migration. CONCLUSIONS: Both PBC placement and neoadjuvant and adjuvant alpha-blocker treatment are effective in alleviating symptoms and improving QOL during the acute period after TUMT. PBC usage also resulted in substantial early Qmax improvement. Either of these adjunctive modalities may be appropriate to consider in the treatment of TUMT patients during the early postprocedure recovery period.

Adrenergic alpha-Antagonists↗

PubMed1999

High-energy transurethral microwave thermotherapy in patients with acute urinary retention due to benign prostatic hyperplasia.

OBJECTIVES: To evaluate the efficacy and safety of targeted high-energy transurethral microwave thermotherapy (HE-TUMT) in the treatment of acute urinary retention (AUR) due to benign prostatic hyperplasia (BPH). METHODS: In this prospective cohort study, 31 patients with painful AUR due to BPH underwent HE-TUMT. Patient evaluation before treatment and during a 12-week follow-up interval included determination of International Prostate Symptom Score (IPSS), quality of life (QOL) score, peak flow rate (Qmax) by uroflowmetry, and postvoid residual urine. Patients also underwent urodynamic evaluation before treatment and at 16 weeks. RESULTS: By 4 weeks after HE-TUMT, 29 (94%) of 31 patients had regained the ability to void spontaneously. The actuarial median time for restoration of spontaneous voiding was 3.0 weeks (95% confidence interval [CI] 2.2 to 3.8). At 12 weeks, the mean IPSS (9.4; 95% CI 8.3 to 10.5) was 50% below (P <0.0005) that before retention (18.9; 95% CI 18.2 to 19.6). Improvements in the mean QOL score were similar in pattern and relative magnitude to those in the mean IPSS. A 69% increase in mean Qmax (P <0.0005) determined by uroflowmetry was observed by 12 weeks versus 1 week after HE-TUMT. Complications were infrequent. CONCLUSIONS: This study provides preliminary evidence that HE-TUMT may potentially afford a novel and useful option for the patient with AUR who is not a suitable candidate for surgery.

Acute Disease↗

PubMed1999

PSA, PSA density, PSA density of transition zone, free/total PSA ratio, and PSA velocity for early detection of prostate cancer in men with serum PSA 2.5 to 4.0 ng/mL.

OBJECTIVES: To enhance the specificity of prostate cancer (PCa) detection and reduce unnecessary biopsies in men with prostate-specific antigen (PSA) levels of 2.5 to 4.0 ng/mL, we prospectively evaluated various PSA-based diagnostic parameters. METHODS: This study included 273 consecutive men with serum PSA of 2.5 to 4.0 ng/mL referred for early PCa detection or lower urinary tract symptoms. All men underwent prostate ultrasound and sextant biopsy with two additional transition zone (TZ) biopsies. If the first biopsies were negative, repeated biopsies were performed at 6 weeks. Total PSA, PSA density (PSAD), PSA density of the transition zone (PSA-TZ), free/total PSA ratio (f/t PSA), and PSA velocity (PSAV) were determined, and the sensitivity, specificity, and predictive values of these various parameters were calculated. RESULTS: Of 273 patients, 207 had histologically confirmed benign prostatic hyperplasia (BPH) and 66 had PCa. f/t PSA and PSA-TZ were the most powerful predictors of PCa, followed by PSA, PSAD, and PSAV. Areas under the receiver operating characteristic curves for f/t PSA and PSA-TZ were 74.9% and 70.1%, respectively. With a 95% sensitivity for PCa detection, an f/t PSA cutoff of 41% and a PSA-TZ cutoff of 0.095 would result in the lowest number of unnecessary biopsies (29.3% and 17.2% specificity for f/t PSA and PSA-TZ, respectively) compared with all other PSA-related parameters evaluated. CONCLUSIONS: Compared with standard total PSA assays, f/t PSA and PSA-TZ significantly enhance the sensitivity and specificity of PCa detection in a referral patient population with a total PSA of 2.5 to 4.0 ng/mL.

Adult↗

PubMed1999

Insulin-like growth factor 1 (IGF-1), IGF-1 density, and IGF-1/PSA ratio for prostate cancer detection.

OBJECTIVES: Recent studies suggest an association between increased serum levels of insulin-like growth factor 1 (IGF-1) and an increased risk of prostate cancer (PCa). We prospectively analyzed the value of IGF-1, IGF-density (IGFD), and IGF-1/prostate-specific antigen (PSA) ratio for early detection of prostate cancer. METHODS: IGF-1, IGFD, and IGF-1/PSA ratio were determined prospectively during an 11-month period in the serum from 245 consecutive white men with PSA levels between 2.5 and 15 ng/mL. Octant biopsy (including transition zone biopsy) was performed. A second biopsy was performed 6 weeks later if the first biopsy was negative. Prostate volume was measured using transrectal ultrasound and the prolate ellipsoid method. Receiver operating characteristic curves were performed to compare tests. RESULTS: No evidence of malignancy was found in 174 patients (71%), and PCa was found in 71 (29%). The mean age for patients with no evidence of malignancy and those with PCa was 67.7+/-9 and 65.7+/-6 years, respectively (P = 0.17). IGF-1, IGFD, IGF-1/PSA ratio, and PSA were significantly higher in patients with PCa than in those with benign disease (P = 0.03, P = 0.045, P = 0.001, and P = 0.018, respectively). The area under the curve value derived from the receiver operating characteristic curves for IGF-1/PSA ratio, PSA, IGFD, and IGF-1 was 71%, 61%, 60%, and 58%, respectively. At 95% sensitivity, the specificity of the IGF-1/PSA ratio was significantly greater than that of all other parameters (P<0.0001 ). An IGF-1/PSA cutoff value of 25 afforded a 95% sensitivity for detecting PCa and would have avoided unnecessary biopsies in 24.1% of patients. CONCLUSIONS: Although IGF-1 and IGFD were unable to enhance the performance of PSA in our study, the IGF-1/PSA ratio significantly improved PCa detection over the use of PSA alone. Thus, increased IGF-1 levels (i.e., the IGF-1/PSA ratio) may not only be associated with an increased PCa risk but may also be a useful tool for early detection.

Aged↗

PubMed1999

The importance of measuring the prostatic transition zone: an anatomical and radiological study.

OBJECTIVE: To assess the accuracy and reliability of measurements of the volume of the transition zone (TZ, representing the hypertrophied benign component) and whole prostate by TRUS in patients with BPH or cancer, by comparing the radiological with pathological findings after surgery. PATIENTS AND METHODS: The study comprised 36 patients with prostate cancer undergoing radical prostatectomy and 34 patients with symptomatic BPH treated using retropubic adenectomy. The weights of the radical prostatectomy specimens and of the enucleated adenomas were correlated with the corresponding volumes of the TZ and of the whole prostate, respectively, measured by TRUS using the prolate ellipsoid method. RESULTS: The mean (sd) TZ volume measured by TRUS was 36.9 (25.48) mL, whereas the weight of the enucleated specimen was 42.7 (33.58) g (correlation coefficient r=0.95, P<0.001). The TRUS estimate of the volume of the whole prostate was 29.2 (9.24) mL, while the radical prostatectomy specimens weighed 34.5 (10.76) g (r=0.78, P<0.001). The variability in the TZ volume estimate ranged from -17% to +18%, whereas the variability for whole prostate was -21% to +30% (P<0.05). CONCLUSIONS: Measurements of the TZ of the prostate by TRUS are more accurate than those for the whole prostate. An assessment of the TZ volume may be sufficiently reliable to be used in the clinical management of BPH and to detect prostate cancer using the prostate-specific antigen density of the TZ as a marker.

Humans↗

PubMed1999

A meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.

OBJECTIVE: To assess whether the alpha1-adrenoceptor antagonists currently available for the treatment of lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) (alfuzosin, terazosin, doxazosin and tamsulosin) can be distinguished with regard to clinical efficacy and/or tolerability. METHODS: Up-to-date analysis of clinical placebo-controlled or direct comparative studies with alpha1-adrenoceptor antagonists in patients with LUTS suggestive of BPO derived from a MEDLINE search in October 1998. All retrieved studies were analyzed with regard to efficacy and tolerability. Efficacy was evaluated by the percentage improvement in total symptom score and Qmax (mean end of study value relative to mean baseline value). Tolerability was evaluated by means of study withdrawal rate because of adverse events and the incidence of vasodilatatory adverse events (e.g. dizziness and orthostatic hypotension). RESULTS: Indirect comparison of data derived from the placebo-controlled studies involving 6,333 patients and the data derived from the direct comparative studies involving 507 patients demonstrate that all alpha1-adrenoceptor antagonists (alfuzosin, terazosin, doxazosin and tamsulosin) produce comparable improvements in LUTS and urinary flow. Total symptom score is in general improved by 30-40% and Qmax by 16-25%. The difference between currently available alpha1-adrenoceptor antagonists is related to their side effect profile. Alfuzosin (especially the sustained release formulation) and tamsulosin (modified release formulation 0.4 mg) seem to be better tolerated than terazosin and doxazosin. The percentage of patients that withdrew due to bothersome side effects with alfuzosin and tamsulosin 0.4 mg was comparable to that with placebo (about 4-10%) whereas in the terazosin and doxazosin studies an additional 4-10% of patients dropped out because they did not tolerate the therapy. Tamsulosin has less effect on blood pressure than alfuzosin (especially in elderly patients) and causes less symptomatic orthostatic hypotension during orthostatic stress testing than terazosin. CONCLUSIONS: All alpha1-adrenoceptor antagonists seem to have similar efficacy in improving symptoms and flow. The difference between alpha1-adrenoceptor antagonists is related to their side effect profile. Alfuzosin and tamsulosin appear to be better tolerated than doxazosin, terazosin and prazosin.

Adrenergic alpha-Antagonists↗

PubMed1999

Prospective randomized comparison of high energy transurethral microwave thermotherapy versus alpha-blocker treatment of patients with benign prostatic hyperplasia.

PURPOSE: We compare directly the efficacy and safety of targeted high energy transurethral microwave thermotherapy with alpha-blocker treatment for benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: In this randomized prospective study 52 patients with symptomatic BPH received terazosin and 51 underwent high energy transurethral microwave therapy with topical anesthesia. Patient evaluation included determination of International Prostate Symptom Score (I-PSS), peak flow rate and quality of life score before transurethral microwave therapy or terazosin and periodically up to 6 months thereafter. RESULTS: At 2-week followup the terazosin group transiently exhibited significantly greater improvement than the transurethral microwave therapy group in mean values of all 3 primary efficacy parameters of I-PSS, peak flow rate and quality of life score. At 12 weeks and 6 months this pattern was reversed, and the transurethral microwave therapy group achieved significantly greater improvement than the terazosin group in mean I-PSS, peak flow rate and quality of life score. By 6 months 78.4, 64.7 and 84.3% of the transurethral microwave therapy group demonstrated a 50% or greater improvement in I-PSS, peak flow rate and quality of life score, respectively, compared with 32.7, 9.6 and 40.4% of the terazosin group, respectively. Nine patients in the terazosin group and 1 in the transurethral microwave therapy group withdrew from study because of side effects or lack of treatment efficacy. CONCLUSIONS: Terazosin afforded more rapid improvement in symptoms, voiding function and quality of life in BPH patients. High energy transurethral microwave therapy offered markedly superior clinical outcomes at 12 weeks to 6 months.

Adrenergic alpha-Antagonists↗

PubMed1999

A novel intraurethral prostatic bridge catheter for prevention of temporary prostatic obstruction following high energy transurethral microwave thermotherapy in patients with benign prostatic hyperplasia.

PURPOSE: We evaluate the efficacy and safety of a novel intraurethral prostatic bridge catheter in preventing temporary prostatic obstruction following targeted high energy transurethral microwave thermotherapy in patients with benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 54 patients with benign prostatic hyperplasia underwent high energy transurethral microwave therapy under topical urethral anesthesia followed by placement of a prostatic bridge catheter, which remained indwelling as long as 1 month (prostatic bridge catheter group). Patient evaluation included determination of peak urinary flow rate, International Prostate Symptom Score (I-PSS) and quality of life score at baseline, immediately following transurethral microwave therapy and prostatic bridge catheter placement, and periodically thereafter for 1 month. Results were retrospectively compared with those of 51 patients who underwent transurethral microwave therapy followed by standard temporary urinary catheterization, typically for 24 hours (standard catheterization group). RESULTS: Immediately following transurethral microwave therapy and prostatic bridge catheter placement significant improvements (p <0.0005) were observed in mean peak flow rate, I-PSS and quality of life score of 59.3, 33.5 and 23.6%, respectively, compared with baseline values. Further improvements were noted up to 1 month, at which time mean peak flow rate, I-PSS and quality of life score had improved 79.0, 54.9 and 56.5%, respectively, versus baseline (p <0.0005). In a retrospective comparison at baseline and 14 days between the prostatic bridge catheter group and standard catheterization group mean baseline peak flow rate, I-PSS and quality of life score were similar. However, at the 14-day followup evaluation in the prostatic bridge catheter group mean peak flow rate was 101.8% higher, and I-PSS and quality of life score were 47.9 and 51.1% lower, respectively, than the corresponding values in the standard catheterization group (p <0.0005). The prostatic bridge catheter was well tolerated and remained indwelling throughout the entire 1-month followup in 48 of 54 patients (88.9%). Early prostatic bridge catheter removal was required in 3 patients (5.6%) due to urinary retention and in 3 (5.6%) due to catheter migration. CONCLUSIONS: Prostatic bridge catheter placement provides an effective and well tolerated option for preventing prostatic obstruction in the acute period after transurethral microwave therapy. This approach avoids the inconvenience and infection risk of standard indwelling catheters or intermittent self-catheterization. Prostatic bridge catheter insertion and removal are rapid, facile, nontraumatic procedures. Prostatic bridge catheter may potentially be used in an array of minimally invasive procedures involving thermal treatment of the prostate gland.

Diathermy↗

PubMed1999

[Prevention of temporary prostatic obstruction after high-energy microwave thermothery by placement of prostatic bridge catheter].

OBJECTIVES: The clinical utility of a novel intraurethral prostatic bridge-catheter (PBC) was evaluated for prevention of temporary prostate obstruction following targeted high-energy transurethral microwave thermotherapy (TUMT) in patients with benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: High-energy TUMT was administered to 54 BPH patients under topical urethral anesthesia followed by placement of a PBC, which remained indwelling up to 1 month. Patient evaluation included determination of peak urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and quality of life (QOL) score at baseline, immediately following TUMT and PBC placement, and at periodic intervals thereafter up to 1 month. Results were compared retrospectively with those of 51 patients who underwent TUMT followed by standard temporary urinary catheterization, generally for 24 h. RESULTS: Immediately following TUMT and PBC placement significant improvements (p < 0.0005) were observed in mean Qmax, IPSS and QOL score of 59.3%, 33.5% and 23.6% respectively, compared with baseline values. Further improvements were demonstrable up to 1 month, at which time mean Qmax, IPSS and QOL score had improved 79.0%, 54.9% and 56.5%, respectively, vs baseline means (p < 0.0005). In a retrospective comparison at baseline and 14 days between PBC recipients (PBC group) and a cohort of TUMT patients who had undergone temporary standard catheterization and subsequent catheter removal (standard catheterization group), mean baseline Qmax, IPSS and QOL score were similar between the two groups. However, at the 14 day follow-up evaluation in the PBC group mean Qmax was 101.8% higher, and IPSS and QOL score were 47.9% and 51.1% lower, respectively, than the corresponding values in the standard catheterization group (p 0.0005). The PBC was well tolerated and remained in situ throughout the entire 1 month follow-up period in 48/54 (88.9%) patients. Early PBC removal was performed in 3/54 patients (5.6%) because of urinary retention and in 3/54 patients (5.6%) due to PBC migration. During the acute post-TUMT recovery period, PBC recipients experienced impairment in sexual function which, though statistically significant, was comparatively small in magnitude. CONCLUSION: PBC provides an efficacious and well-tolerated option for preventing prostatic obstruction in the acute post-TUMT period. This approach avoids the inconvenience and infection risk of standard indwelling catheters or intermittent self-catheterization. PBC insertion and removal are rapid, facile and non-traumatic. PBC placement may prove useful in improving the early results of TUMT.

Aged↗

PubMed1999

Outcome analysis of minimally invasive treatments for benign prostatic hyperplasia.

The armamentarium of minimally invasive treatment modalities for patients with benign prostatic hyperplasia has increased steadily during the past decade. The energy sources used range from microwaves and radiofrequency waves to high-intensity focused ultrasound, with laser vaporization/coagulation/resection and electrosurgical techniques. The large amount of data available allow some conclusions to be drawn concerning the present role of the "gold standard" TURP among the minimally invasive procedures. Although the subjective response after TURP and other minimally invasive procedures is comparable, improvements of flow and urodynamic parameters usually are more pronounced after TURP. Failure rates requiring reintervention (usually TURP) are considerable. Minimally invasive procedures lead to a shift of morbidity from the intraoperative phase, which is reduced (risk of bleeding, TUR syndrome, transfusion) to the postoperative phase. This period is characterized by prolonged urinary retention (ILC, VLAP), significant dysuria (VLAP, TUVP), and nycturia. Recent advances in electrosurgical techniques, such as band TURP loops that facilitate coagulation due to the longer contact time between the electrode and the tissue, have the potential to convert TURP into a less invasive procedure. Finally, high-energy TUMT seems to offer a truly minimally invasive treatment combining efficacy and the need for topical anesthesia only. However, due to a lack of homogeneity of criteria for patient recruitment, parameters of evaluation, and adequate follow-up; accurate guidelines for appropriate patient management have not been established yet.

Catheter Ablation↗

PubMed1999

Combination and multivariate analysis of PSA-based parameters for prostate cancer prediction.

The aim of this study was to evaluate the ability of prostate-specific antigen (PSA)-based parameters including PSA density (PSAD), PSAD of the transition zone (PSA-TZ), percent free PSA, PSA velocity, and their combination to enhance the specificity of PSA for prostate cancer detection in men with serum PSA levels between 4 and 10 ng/mL. We evaluated prospectively 559 consecutive men referred for early detection of prostate cancer who had serum PSA levels between 4 and 10 ng/mL. All men underwent prostatic ultrasonography and sextant biopsy with two additional TZ biopsies. In all cases, if first biopsies were negative an additional set of biopsies was obtained within 6 weeks. The ability of PSAD, PSA-TZ, PSA velocity, percent free PSA, and their combination to improve the detection of prostate cancer was evaluated by univariate and multivariate analysis as well as receiver operating characteristic (ROC) curves. In this prospective study of 559 patients, 217 had prostate cancer and 342 had histologically confirmed benign prostatic hyperplasia. Multivariate analysis and ROC curves showed that PSA-TZ and percent free PSA (f/t PSA) were the most powerful and highly significant predictors of prostate cancer. Areas under the ROC curve (AUC) for PSA-TZ and percent free PSA were 0.827 and 0.778, respectively (p = .01). Combination of f/t PSA with PSA-TZ (AUC = 88.1%) significantly increased AUC as compared to each of the other parameters alone as well as their combination (p = .02). The next best combinations were PSA-TZ + PSAD, PSA-TZ + PSA, and f/t PSA + PSA. PSA-TZ followed by f/t PSA and PSAD were the most powerful predictors of prostate cancer in referred patients with a serum PSA between 4 and 10 ng/mL. f/t PSA + PSA-TZ was the most effective combination. When volume-independent PSA parameters were taken into consideration, f/t PSA + PSA clearly outperformed the other options.

Aged↗

PubMed1999

Predictability and significance of multifocal prostate cancer in the radical prostatectomy specimen.

Multifocal prostate cancer has been reported in 50-76% of all cases of radical retropubic prostatectomy (RRP) specimens, but the clinical and prognostic significance of this finding is still unclear. A retrospective analysis of patients who underwent RRP between 1993 and 1997 was performed. Preoperative screening parameters and 4-mm RRP specimen sections were examined. The location, Gleason score, and extracapsular extension of the tumor recorded. Three hundred eight cases were reviewed. Mean follow-up was 4.2 +/- 1 years (range 2-6 years). Two hundred six patients (66.9%) had multifocal prostate cancer and 102 (33.1%) had unifocal prostate cancer. Of those with multifocal disease, 63% had two foci and 37% had three or more foci. There were statistical significant differences between both groups with respect to preoperative prostate-specific antigen (PSA) density of the transition zone (PSA-TZ), free/total (f/t) PSA, as well as percentage of patients with organ confined disease, high-grade tumors, and local recurrence. PSA-TZ (p = .001) and f/t PSA (p = .004) were significantly different between patients with unifocal and multifocal disease (0.9 vs. 2.2 ng/mL/cc and 18% vs. 6.5%, respectively). However, preoperative PSA (11.2 vs. 12.8 ng/mL; p = .09) and PSA density (0.17 vs. 0.19 ng/mL/cc; p = .07) were not able to predict unifocality or multifocality. These data suggest that multifocal prostate cancer is associated with higher grade, stage, and recurrence rate than unifocal prostate cancer. Preoperative PSA-TZ (> 1.5 ng/mL/cc) and f/t PSA (<9%) may predict multifocality in the RRP specimen.

Aged↗

PubMed1998

Tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia: results of a prospective, randomized, single-blinded clinical trial.

PURPOSE: We determine the tolerability of high energy transurethral microwave thermotherapy with topical urethral anesthesia alone without supplementary systemic sedoanalgesia. MATERIALS AND METHODS: A total of 45 patients with symptomatic benign prostatic hyperplasia were randomized to high energy transurethral microwave thermotherapy using either topical urethral anesthesia alone (topical anesthesia group) or topical anesthesia with adjunctive intravenous sedoanalgesia (sedoanalgesia group). Pain was evaluated sequentially by means of a 0 to 10 visual analog scale score. Posttreatment followup included determinations of International Prostate Symptom Score, peak flow rate, post-void residual urine, and quality of life score at 6 and 12 weeks. RESULTS: Upon commencement of microwave treatment mean visual analog scale score was 1.3 (95% confidence interval [CI], 1.0 to 1.7) in the sedoanalgesia group and 1.4 (95% CI, 1.0 to 1.9) in the topical anesthesia group. During therapy visual analog scale score increased to a peak at 30 minutes of 2.0 (95% CI, 1.6 to 2.4) and 2.2 (95% CI, 1.7 to 2.6) in the sedoanalgesia and topical anesthesia groups, respectively. Thereafter, visual analog scale score continuously declined, falling to 0.1 (95% CI, 0.0 to 0.2) and 0.2 (95% CI, 0.0 to 0.3) in the 2 respective groups by 1 hour following conclusion of the treatment period. There was no statistically significant difference between the groups in the treatment profile of visual analog scale scores (p = 0.701). Significant posttreatment improvements were demonstrated in International Prostate Symptom Score, peak flow rate, post-void residual urine and quality of life scores but there were no significant differences between the groups in the magnitude of improvement in these outcome measures. CONCLUSIONS: High energy transurethral microwave thermotherapy is well tolerated by patients under topical anesthesia alone and, therefore, can be administered in the outpatient setting without potent medications that necessitate intensive patient monitoring, pose risks for side effects and add to treatment costs.

Aged↗

PubMed1998

Morbidity of the evaluation of the lower urinary tract with transurethral multichannel pressure-flow studies.

PURPOSE: The aim of this prospective study was to determine morbidity and complication rate of invasive urodynamic evaluation of the lower urinary tract after transurethral multichannel pressure-flow studies. MATERIALS AND METHODS: The study included 63 men with the clinical diagnosis of benign prostatic hyperplasia and 56 women with stress urinary incontinence. All patients underwent routine pressure-flow study as part of the urodynamic evaluation. A week later the patients returned for followup which also included a detailed interview on post-evaluation morbidity. RESULTS: The overall complication rate, including urinary retention, gross hematuria, urinary tract infection and fever, was 19.0% (12 of 63) for men and 1.8% (1 of 56) for women. In men there was no statistically significant correlation between post-void residual urine or age and complication rate (p > 0.05). Of the men 4.8% experienced post-investigational urinary retention and all of them had significant bladder outflow obstruction. In addition, obstructed men reported a higher incidence of dysuria and pain (76.2%, 32 of 42) compared to those without obstruction (57.1%, 12 of 21), whereas only 53.6% of women reported these complaints. Of the 63 men 4 (6.2%) had significant urinary tract infections, while only 1 woman (1.8%) had infections. CONCLUSIONS: Invasive urodynamic investigation is associated with a considerable rate of complications and morbidity, particularly in men with infravesical obstruction. These facts must be considered and discussed with the patient before urodynamic testing.

Adult↗