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Purpose: To compare prostate shrinkage after transurethral microwave thermotherapy (TUMT) with calculated cell-kill., Materials and Methods: The calculated cell-kill from 33 males with benign prostatic hyperplasia (BPH) treated with TUMT according to the ProstaLund Feedback Treatment (PLFT) method was compared to the post-treatment prostate volume change. The prostate volume was estimated with three-dimensional transrectal ultrasound (3D-TRUS) planimetry at baseline, 3, 6, and 12 months follow-up. A paired t-test was used to test the statistical significance of differences between the cell-kill volume and the prostate volume change. Linear regression was used to infer a relationship between the cell-kill and the 3D-TRUS data. The reproducibility of the 3D-TRUS method was assessed in repeated measurements., Results: The mean prostate volume at baseline (N=33) was 56.1cm(3). After 3 (N=25), 6 (N=29) and 12 months (N=23), it was 45.5 cm(3), 39.7 cm(3), and 45.1cm(3), respectively. The corresponding average cell-kill volume was 16.4 cm(3), 17.1cm(3), and 17.2 cm(3), respectively. Predicted cell-kill volume was significantly larger than prostate shrinkage at 3 (p<0.0001), 6 (p=0.0002), and 12 months (p<0.0001), and showed a strong correlation at 3 and 6 months (r=0.74, p<0.0001). Correlation at 12 months was moderate (r=0.57, p=0.0041). Examination and investigation variability both averaged 2.5%., Conclusions: Cell-kill calculations of the PLFT method are proportional to the 3D-TRUS prostate shrinkage by a factor of 0.5 and have a precision of approximately +/-10 cm(3) for 90% of the patients during the first year after treatment.

Objectives: The objective of this study is to define enhancement characteristics that correlate to the presence of prostate cancer (PCa) and to evaluate the value of these characteristics in the localization of prostate cancer., Methods: 29 patients with proven prostate malignancy, scheduled for radical prostatectomy, underwent an ultrasound examination prior to surgery. A bolus injection of contrast agent was administered intravenously. The distribution of the contrast enhanced blood to the prostate was monitored using Transrectal Contrast Enhanced Power Doppler Ultrasound. Fixed protocols and settings were used for all patients. The percentage of a selected area that showed enhancement was observed in time. The resulting enhancement curves were described using the parameters time to start, time to the maximum of the enhancement, the maximum value of the enhancement, and the rise time of the enhancement. Three evaluation-protocols divided the prostate into a number of areas of interest: into two areas using the Left-Right (LR) and Dorsal-Ventral (DV) protocols and into four areas using the Quadrant-protocol (Q). The enhancement parameters of the areas of interest were compared to identify the most affected area. The results were compared to the histopathological findings., Results: For the LR-protocol, the minimal time to peak proved to be the most predictive parameter for selecting the major malignant area. 78% of the patients were diagnosed correctly (N=23). Accurate localization of the major malignancy in either the ventral or dorsal side of the prostate was not feasible using the current protocol., Conclusions: Malignancies can be accurately localized in either the left or the right side of the prostate based on the time to the maximum of the enhancement. An accurate discrimination between malignancies in either the dorsal or ventral side of the prostate cannot be performed. This is most likely due to anatomical differences between the dorsal and ventral area.

Background: The presented study has investigated a possible improvement of imaging prostate cancer: three-dimensional contrast-enhanced power Doppler ultrasonography (3D-CE-PDU)., Methods: Seventy patients with biopsy proven prostate cancer and scheduled for radical retropubic prostatectomy received a 3D-CE-PDU investigation before surgery. Two experts analyzed the ultrasound images. The ultrasound images were correlated to the whole-mount sections of the prostate specimen. The correlation protocol consisted of three evaluation steps., Results: In total, 153 prostate tumors were found in the 70 prostate specimens: 61 tumors <5 mm, 93 tumors >or=5 mm. The diagnosis of clinical significant and insignificant prostate cancer was made in 85 and 88% of the patients for expert I and II, respectively. Diagnosis by imaging improved from 61% (43 of 70 of the prostate cancers) for standard detection tools to an average 86% (60 of 70 prostate cancers) for 3D-CE-PDU., Conclusion: 3D-CE-PDU improves the detection of prostate cancer in this group of prostate cancer patients. The use of 3D-CE-PDU in the clinic is questionable as indications are still unclear., (Copyright 2002 Wiley-Liss, Inc.)

Objective: Given the high possibility of co-occurrence of benign prostatic hyperplasia (BPH) and cardiovascular disease, we evaluated whether patients using BPH drugs are at an increased risk of acute hospital admission for ischemic heart disease (IHD)., Methods: A nested case control study within a cohort of 4414 men (aged > or =30 years) who had a history of using BPH products between 1992 and 1998 was conducted. Cases were defined as men with a first record of an acute hospital admission for IHD during the study period; three controls were matched to each case on year of birth, pharmacy and calendar time (index date)., Results: The study population comprised 220 cases and 515 controls. Current use of alpha-blockers (adjusted odds ratio 1.0, 95% confidence interval: 0.5-2.2) or finasteride (adjusted odds ratio 0.3, 95% CI: 0.1-1.4) was not associated with hospital admission for IHD. Furthermore, current use of BPH drugs was not associated with IHD in patient subgroups (age, history of cardiovascular disease, diabetes), nor with duration of use prior to hospitalization., Conclusion: Although the power of the study was low, we found no evidence for an association between current use of BPH drugs and hospital admission for IHD. Therefore, our study seems to confirm the good cardiovascular safety profile of modern BPH drugs.

Objectives: To review the current status of the Laparoscopic Radical Prostatectomy in Europe (LRP)., Methods: The published peer reviewed articles on the experience of the European groups performing Laparoscopic Radical Prostatectomy., Results: Three different approaches have been described for LRP, two of them transperitoneally (early dissection of seminal vesicles or of the prostatic apex) and one totally extra peritoneally. Results in terms of per operative performances and immediate outcomes seem to be comparable with the exception of the bleeding and the transfusion rate that seem higher in the transperitoneal approach with early dissection of the prostatic apex. Conversion rates have been described up to 5% but it is rare after the 20 first cases; after the learning curve has been overcome the complication rate varies between 10% and 17%. Being a novel technique, all the series have a short median follow-up of around one year. The one-year continence rates are comparable to the ones described with the classical open approach, as it is the potency rate. The rate of positive margins bounces between 2 and 49% depending mainly on case selection. A long and steady learning curve burdens the technique in terms of complications., Conclusions: LRP is feasible, teachable and reproducible. Although no comparative series with the open approach are available yet, functional and oncological results seem to be comparable to the ones reached after open Retropubic Radical Prostatectomy.

Background: We quantified changes in prostate carcinoma vascularity treated with anti-androgens using color Doppler and power transrectal ultrasound in combination with microbubble contrast agent Levovist., Methods: Thirty-six men with prostate carcinoma were studied at baseline and at intervals during treatment. At each attendance, Levovist((R)) (10 ml, 300 mg/ml) was given as an iv bolus. Using quantitative analysis, we calculated the pre-enhancement scores, arrival time, time to peak, peak value, and area under the time-enhancement curve (AUC). These were compared to pre-treatment values and serial PSA measurements., Results: The pre-enhancement, peak value, and AUC each showed a marked response with reductions within one week. The average AUC declined to 68% +/- 9% (mean +/- standard error) by week 1, 56% +/- 9% by week 3, and 20% +/- 4% by week 6. A strong correlation with changes in the mean PSA (r = 0.95, P < 0.001) was also measured. In four patients, Doppler indices did not fall with PSA: two patients with the most marked discrepancy relapsed at 6 months., Conclusion: The vascular enhancement declined with therapy, similar to PSA. Microbubble enhanced ultrasound can show early response to treatment., (Copyright 2002 Wiley-Liss, Inc.)

Purpose: We assessed the prognostic value of baseline prostate specific antigen (PSA) for outcome after high energy transurethral thermotherapy in patients with lower urinary tract symptoms., Material and Methods: Data were collected prospectively in 404 consecutive patients treated with high energy transurethral thermotherapy with the Prostatron device (EDAP-Technomed, Lyon, France). Patients were followed a minimum of 1 year. At baseline certain criteria were assessed, including pretreatment PSA, uroflowmetry, ultrasound measurement of prostatic volume, voided and post-void residual urine volume, and International Prostate Symptom Score (I-PSS) and quality of life scores. Outcome assessment included I-PSS, quality of life score and uroflowmetry of peak urine flow. Linear regression analyses were performed to correlate baseline PSA with improved clinical parameters at 12 months of followup. Logistic regression analyses and receiver operating characteristics curves characterized the ability of baseline PSA to discriminate patients with a more or less favorable outcome., Results: An evident linear association was identified for prostate size at baseline and PSA. After 1 year 36 patients were treated again due to transurethral thermotherapy failure and 16 had died, which was not related to lower urinary tract symptoms or treatment for lower urinary tract symptoms. To include re-treated patients in the analyses we considered that their I-PSS, quality of life and peak urine flow values at 1 year were unchanged compared with baseline. Of the 388 evaluable patients an improvement of 50% or more in I-PSS, quality of life and peak urine flow was observed in 57%, 62% and 44%, respectively. Absolute mean changes at 1 year were -9.7, -2 and 5.2 ml. per second for I-PSS, quality of life and peak urine flow, respectively. Neither linear nor logistic regression analysis showed any clinically relevant correlation between baseline PSA and changes in I-PSS (r = -0.004), quality of life (r = -0.135) or peak urine flow (r = 0.105) at 1 year. Receiver operating characteristics curves failed to distinguish more or less favorable outcomes in all evaluated parameters., Conclusions: Pretreatment PSA cannot predict the clinical outcome after high energy transurethral thermotherapy.

Purpose: The efficacy of alpha-adrenoceptor blockers for the treatment of lower urinary tract symptoms has been proven in numerous studies. However, little is known about the efficacy of the longer term. We investigated the long-term risk of re-treatment in patients using alpha-adrenoceptor blockers for lower urinary tract symptoms and the parameters that influence this risk., Materials and Methods: We reviewed the files of 316 patients with lower urinary tract symptoms treated at our department with the alpha-blockers terazosin, alfuzosin or tamsulosin. Using followup data up to 3 years, we calculated re-treatment percentages in each treatment group. Using extended followup of 5 years, we calculated the predictive value of various baseline characteristics for re-treatment., Results: The re-treatment rates were 27% for tamsulosin, 37% for alfuzosin and 49% for terazosin. The re-treatment rates of patients with mild, moderate and severe lower urinary tract symptoms were 27%, 33% and 70%, respectively. Patients with a maximum urine flow of less or more than 10 ml. per second had a re-treatment rate of 58% and 47%, respectively. Patients with a prostate volume of less or more than 40 ml. had a re-treatment rate of 48% and 72%, respectively. Patients who were urodynamically unobstructed versus obstructed patients had a re-treatment rate of 44% and 59%, respectively., Conclusions: Patients given alpha-blockers for lower urinary tract symptoms have a high risk of re-treatment. Tamsulosin has a markedly lower re-treatment percentage than alfuzosin and terazosin. Severe symptoms, poor urine flow, an enlarged prostate and urodynamically proven bladder outlet obstruction increase the risk of treatment failure. Preselection of the most suitable candidates for alpha-blockade may reduce this risk.

Objectives: To investigate whether volume adjustment can be used to reduce the within-patient variability of the maximal urinary flow rate (Qmax) without affecting the variability between patients., Methods: We analyzed 2049 urinary flow curves of 208 men with lower urinary tract symptoms suggestive of bladder outlet obstruction and studied the relation between Qmax and voided volume (VV) in individual patients using multilevel regression analysis., Results: In agreement with most previous studies, we found a hyperbolic relation between the VV and Qmax. Although hyperbolic on average, the slope of the regression line relating the VV to Qmax differed substantially across individual patients. In some patients, Qmax even tended to be lower with an increased VV., Conclusions: The reproducibility of Qmax is poor, in part because of its dependence on the VV. The current methods to adjust Qmax for VV, such as the Siroky nomogram, minimize between-patient dependency, whereas our findings emphasize the importance of within-patient variability. A common approach to adjust Qmax for VV, however, is not feasible, because the relation of Qmax to VV differs substantially across patients. The only valid, although impractical option, remains to record a large number of urinary flow curves for each patient.

Objectives: To evaluate the relative accuracy of a computerised method to quantitatively assess maximum urinary flow., Methods: A total of 1147 uroflows were evaluated by the computerised method and by three experts from different European countries. The sample consisted of uroflows from the respective visits by a 20% sample of randomly chosen patients (n = 223) with lower urinary tract symptoms with participation in two clinical trials in which the efficacy and safety of Permixon was evaluated. The proportions of automated maximum flow values included in the 10% extended range of experts (and their 95% confidence intervals) were assessed, as well as the concordance coefficients between experts and the computerised method and the paired Student's t-test for the average differences between experts and computer., Results: The rate of agreement between experts and computer varied between about 95 and 100% over factor levels for visit, type of machine and country. Concordance coefficients indicated good agreement between experts and the automated method. When looking at average differences between experts and the computer, the smallest differences were observed between experts 2, 3 and the computer (differences not statistically significant). Statistically significant average differences were observed between expert 1 and the other experts as well as between expert 1 and the computer., Conclusions: The computerised assessment decreases the fraction of variability of maximum urinary flow caused by artifacts as well as intra- and inter-expert variation. The computerised assessment of maximum urinary flow is an efficient, consistent and valid approach to quantitatively assess maximum urinary flow in clinical trials.

Guidelines within the healthcare system aim to rationalize the diagnosis, treatment and follow-up of a particular disease and can be applicable on an international scale or may be country specific. Specialists, who determine the clinical evidence for individual practices, prepare these guidelines, and the strength of these recommendations depends on available evidence. The assessment of patients includes a minimal number of non-invasive tests. Only in cases of abnormalities are additional (more invasive) tests recommended. Treatment decisions should be evidence-based but, despite guidelines, the choice of treatment is often highly dependent on the personal preference of the urologist. Patients' awareness of different treatment options and their involvement in choosing a treatment is also increasing. Economical aspects are becoming more and more important in making healthcare decisions. Data on durability of treatments, however, are limited and deserve special attention in order to provide the most cost-effective care for different patient groups.

Purpose: We reviewed the current status of the endoscopic distal ureteral approach to nephroureterectomy for transitional upper urinary tract cancer., Material and Methods: We reviewed the English, French and Spanish literature using a PubMed and MEDLINE search, and compared the stripping and pluck techniques. Statistical analysis was done using Fisher's exact test. Individual case reports are discussed but they were not included in the statistical analysis., Results: The mean rate of bladder carcinoma recurrence after ureteral resection and detachment is 19.3% for the stripping and 24% for the pluck technique. This difference is not statistically significant. In 3.1% of cases invasive bladder cancer has been noted but only after distal ureteral resection using the pluck technique., Conclusions: The endoscopic approach to the distal ureter during nephroureterectomy is feasible. Bladder cancer recurrence was similar after each technique. However, isolated case reports illustrate the need for cautious selection of surgical candidates.

Objective: To establish guidelines for the diagnosis, treatment, and follow-up of BPH., Methods: A search of published work was conducted using Medline. In combination with expert opinions recommendations were made on the usefulness of tests for assessment and follow-up: mandatory, recommended, or optional. In addition, indications and outcomes for the different therapeutic options were reviewed., Results: A digital rectal examination is mandatory in the assessment for the diagnosis of BPH. Recommended tests are the International Prostate Symptom Score, creatinine measurement (or renal ultrasound), uroflowmetry, and postvoid residual urine volume. All other tests are optional. The aim of treatment is to improve patients' quality of life, and it depends on the severity of the symptoms of BPH. The watchful waiting policy is recommended for patients with mild symptoms, medical treatment for patients with mild-moderate symptoms, and surgery for patients who failed medication or conservative management and who have moderate-severe symptoms, and/or complications of BPH which require surgery. Regarding non-surgical treatments, transurethral microwave thermotherapy is the most attractive option. These treatments should be reserved for patients who prefer to avoid surgery or who no longer respond favourably to medication. Finally, recommendations for follow-up tests and a recommended follow-up time schedule after BPH treatment are provided., Conclusions: Recommendations for assessment, possible therapeutic options, and follow-up of patients with BPH are made.

Objective: Increased microvessel density (MVD) of prostate cancer seems to be associated with poor prognosis and higher stage. Assessment of MVD using noninvasive methods could be of use in the work-up of patients with prostate cancer. The aim of the present study was to correlate three-dimensional contrast-enhanced power Doppler ultrasound (3D-CE-PDU) findings with MVD characteristics of radical prostatectomy specimens., Methods: Seven patients with biopsy-proven prostate cancer had 3D-CE-PDU investigations 2-3 weeks after prostate biopsies were taken and prior to radical prostatectomy. The investigations were performed using Levovist contrast agent (Schering AG, Berlin, Germany) in combination with a Voluson 530D ultrasound scanner (Kretz AG, Zipf, Austria). The 7 patients were selected because of lateralization of the contrast enhancement. Histology slides were made of the side with 'contrast enhancement' and of the contralateral 'unenhanced' side and stained according to the catalyzed reporter deposition (CARD) amplification procedure, and MVD parameters were obtained., Results: In all patients the MVD count of the 'enhanced' side was higher than the MVD count of the 'unenhanced' side, averaging 1.93 times higher. On histology all enhanced lesions proved to contain prostate cancer tissue (average maximum diameter 25 mm (range 17-31)). Two patients had a small bilateral tumor lesion (4 and 5 mm respectively) and in total 5 patients had even smaller satellite lesions (1-2 mm). The smaller lesions were not identified using 3D-CE-PDU., Conclusions: The present study shows that 3D power Doppler contrast ultrasonography is a minimally invasive imaging modality, which has the potential to visualize lesions with increased MVD. This property of 3D-CE-PDU could be used in the detection of prostate cancer.

Objectives: Transrectal ultrasound (TRUS) is an important tool in diagnosing prostate cancer. However, specificity and sensitivity of conventional grey-scale TRUS for the detection of prostate cancer are disappointingly low. New ultrasound modalities are designed to overcome the disappointing results and improve the use of ultrasound in the diagnosis of prostate cancer. This work is a review of the recent literature, combined with own experiences., Methods: The papers were collected using a Medline search, combined with some papers by author selection. The terms used for the Medline search included among other things: transrectal ultrasound, prostate, prostate cancer, prostate biopsies, colour Doppler ultrasound, power Doppler ultrasound, contrast ultrasound. The authors used their own experiences for illustrations of various techniques., Results and Conclusions: Although several modalities show a significant improvement in sensitivity and specificity for the detection of prostate cancer, none of the TRUS modalities discussed can replace prostate biopsies as a definitive diagnostic. Several techniques, especially contrast ultrasound, show definitive promise. However, two valid conclusions can be made from the data presented. First: with today's technology, none of the TRUS modalities discussed can replace systemic biopsies in the early detection of prostate cancer. Second: none of the discussed TRUS modalities has found a definitive place in routine clinical practice.

The inclusion of a determinate technique among the "minimally invasive treatments" of the symptoms due to benign prostatic hyperplasia is a long and careful process. The technique has to be more patient-friendly than conventional techniques, but also needs to be time-tested against older methods. Most of these minimally invasive treatments are based upon distinct types of thermoablation; the method discussed here, hot water balloon thermoablation, is based on the heat conductive properties of the prostatic tissue.

When studying the effects of drug exposure in diseases with a long asymptomatic clinical course, exposure classification may be biased by the gradually developing "visibility" of the disease. Benign prostatic hyperplasia (BPH) is such a disease. We found that cardiovascular morbidity is two times more prevalent in patients starting drug treatment for BPH when compared to age-matched population controls. This resulted in a difference of cardiovascular prognostic factors between the exposed and non-exposed. This feature can jeopardize the validity of non-randomized comparisons of drug effects. Moreover, the existence of non-treatment strategies, disease under-reporting, and an elderly population with a high baseline risk of experiencing (cardiovascular) outcome events were encountered as methodological problems. When studying adverse cardiovascular effects in patients using BPH products in a non-randomized fashion, an important question is whether we can measure in the database all relevant prognostic factors and use the information for statistical adjustment. This question is an important challenge to observational research and once again stresses the need for control of possible biases in choosing an appropriate study design.

Objectives: To compare the accuracy of the detection, localization, and staging of prostate cancer using transrectal three-dimensional (3D) grayscale ultrasonography (3D-US) with conventional transrectal two-dimensional grayscale ultrasonography (2D-US)., Methods: Fifty patients with clinical localized prostate cancer scheduled to undergo radical retropubic prostatectomy and 50 patients with clinical benign prostatic hyperplasia underwent transrectal ultrasound investigations (2D and 3D). The prostate images were retrospectively analyzed by two ultrasound experts unaware of the clinical findings. The images of the prostate cancer group were correlated with the whole-mount histologic specimens of the prostate., Results: All percentages are given for experts 1 and 2. The sensitivity, specificity, and accuracy for the detection of prostate cancer without considering the definitive localization of the tumor for 2D-US was 72% and 76%, 50% and 54%, and 63% and 64%, respectively; for 3D-US, the rates were 82% and 88%, 40% and 42%, and 61% and 65%. The sensitivity, specificity, and accuracy of the combination of 2D-US with 3D-US was 88% and 90%, 36% and 38%, and 62% and 64%, respectively. The sensitivity, specificity, and accuracy for the exact localization of the prostate tumor for 2D-US was 44% and 46%, 50% and 54%, and 47% and 50%, respectively; for 3D-US, they were 52% and 62%, 40% and 42%, and 46% and 52%. The staging of prostate cancer using 3D-US was correct in 49% (expert 1) and in 57% (expert 2) of patients. No difference was observed between 2D-US and 3D-US for accurate staging. Both experts judged the interpretation of 3D-US images as superior to that of 2D-US images., Conclusions: Although 3D-US had statistically significant increased sensitivity in the detection of lesions and decreased specificity compared with 2D-US, 3D-US did not result in significant clinical improvement in the detection and staging of prostate cancer.

Purpose: We evaluate the durable effect of high-energy transurethral microwave thermotherapy and transurethral prostatic resection for treatment of patients with lower urinary tract symptoms suggestive of bladder outflow obstruction., Materials and Methods: Between January 1996 and March 1997, 155 patients with lower urinary tract symptoms suggestive of bladder outflow obstruction were randomized to receive transurethral microwave thermotherapy (Prostatron*; device and commercial software) (82) or undergo transurethral prostatic resection (73). Initial patient evaluation was performed according to international standards. Patients were followed annually with the International Prostate Symptom Score (I-PSS) and uroflowmetry (maximum flow rate). The Kaplan-Meier survival analysis was used to calculate the cumulative risk of re-treatment, adjusted for loss to followup., Results: A total of 78 patients received transurethral microwave thermotherapy and 66 underwent transurethral prostatic resection. Median followup was 33 months. In the thermotherapy group mean maximum urinary flow rate improved from 9.2 ml. per second at baseline to 15.1, 14.5 and 11.9 ml. per second at 1, 2 and 3 years, and mean I-PSS decreased from 20 to 8, 9, and 12, respectively. In the resection group the corresponding numbers for maximum urinary flow rate were 7.8, 24.5, 23.0 and 24.7 ml. per second at 1, 2 and 3 years, and for I-PSS were 20, 3, 4 and 3, respectively. At 36 months, 14 patients in the thermotherapy and 8 from the resection groups underwent re-treatment, and the cumulative risk was 19.8% (95% confidence interval 10.4% to 29.3%) and 12.9% (4.5% to 21.3%), respectively (p = 0.28)., Conclusions: Transurethral microwave thermotherapy and transurethral prostatic resection achieve durable improvement in patients with lower urinary tract symptoms suggestive of bladder outflow obstruction, while the magnitude of improvement is higher with resection. The repeat thermotherapy is based on failure of therapy whereas repeat resection is based on complications of therapy.

Transrectal three-dimensional (3-D) contrast-enhanced power Doppler ultrasound (US) is a novel technique for studying possible prostate malignancy. Before studies can be performed to investigate the clinical validity of the technique, reproducibility of the contrast US studies must be proven. Reproducibility of contrast US was studied in 10 patients with biopsy-proven prostate cancer. The studies performed included static investigations and dynamic investigations of the prostate vasculature. All studies were double performed. The assessment of reproducibility was done objectively using a computer program and, subjectively, by visual assessment. The results indicate high reproducibility of static contrast investigations, for both the objective and subjective assessment. The subjective assessment of the dynamic studies was also highly reproducible. The objective assessment of the dynamic contrast studies, however, was less reproducible, mainly due to motion artefact. We concluded that, especially static 3-D contrast-enhanced, power Doppler investigations of the prostate are highly reproducible.

Background: Blood perfusion regulates intraprostatic temperatures during transurethral microwave thermotherapy (TUMT). We evaluated baseline intraprostatic vasculature, as a predictor of efficacy of TUMT., Methods: Twenty-two patients, with lower urinary tract symptoms (LUTS) suggestive of bladder outflow obstruction, were treated with TUMT (Prostatron). At baseline, three-dimensional contrast-enhanced power-flow-Doppler prostate ultrasonography (3D-CE-PFD) was performed. Assuming that the percentage of perfused area (PPA) is a realistic measure of blood flow, it was used to quantify intraprostatic vasculature., Results: The median (range) age, prostate size, and energy delivered were 66 years (48-80), 47 cm(3) (30-121), 110 kJ (29-136), respectively. The response was 77% (5 failures). The median (range) PPA was 2.76% (0.7-11.3). No difference in PPA among good and poor responders was detected nor was any correlation between PPA and baseline parameters., Conclusions: The baseline intraprostatic vascularization, documented by CE-PFD studies, has no predictive value for the efficacy of TUMT. It seems that "static" baseline blood flow does not reflect the "dynamic" thermoregulatory role of blood flow during treatment., (Copyright 2001 Wiley-Liss, Inc.)

The introduction of contrast agents has changed the diagnostic role of ultrasonography dramatically. Advanced ultrasound techniques, although currently largely unexplored, especially for prostate applications, were introduced to improve, for example, differential diagnosis. Also, new technologies became available using the interaction of the angioemboli with the transmitted ultrasound waves, and sensitive methods to detect microbubbles were developed. As the traveling of microbubbles through the vascular system is a dynamic process, new information becomes available: when the concentration of the contrast agent can be determined as a function of time, a measure for the actual blood flow can be obtained that provides quantitative information. Initially developed to enhance the ultrasound examinations in cardiac applications, contrast agents can currently be found in radiologic applications as well. The first reports of enhanced Doppler examinations of prostatic blood flow have been published, and the results indicate that contrast agents are a promising addition to the conventional ultrasound examination. In this paper, we present a short overview of the status of transrectal ultrasound imaging in prostate cancer, background information on contrast agents and imaging modalities, and early results of enhanced Doppler studies of the prostate to identify cancer. The early results suggest the feasibility of using angioemboli to enhance ultrasound imaging of prostate diseases, and although many issues remain to be solved, angioemboli in combination with a dedicated imaging modality have the potential to improve the diagnostic application of ultrasound in evaluating the prostate for disease.

Objective: Knowledge regarding cell biologic characteristics of small solid glandular buds in the prostate and their relationship with branching activity in the human prostate is still fragmentary. Our object was to demonstrate, on the basis of immunophenotype, loci that harbor the potential for branching activity within the adult human prostate., Materials and Methods: Semiserial sectioning was performed on 13 adult prostates in an effort to identify structures in the prostate that could be considered foci of growth. Selected slides were stained with biomarkers for basal/luminal cells (keratins), proliferation (MIB-1), apoptosis inhibitor (bcl-2), intercellular adhesion (E-cadherin), and stromal-epithelial interactions (tenascin-C). Results were compared with fetal and prepubertal human prostates and microdissected rat prostates., Results: Five histologic epithelial structures were identified in 19 paraffin blocks, which on serial sectioning showed morphologic transitions with a common pattern, consisting of reduction in number and caliber of acini until small solid buds of epithelial cells were reached. Immunophenotypically, the small solid glandular buds had a basal-cell keratin phenotype, expression of bcl-2 in virtually all cells, high proliferative activity, prominent intracellular localization of E-cadherin, and enhanced periglandular tenascin-C immunoreactivity. The budding tips in fetal and prepubertal prostates revealed an immunostaining pattern identical to the small solid glandular buds in the adult, but different to the rat prostate., Conclusions: Our data suggest that dispersed small solid glandular buds have a capacity for growth, and as such may be considered foci of resumed reawakening branching activity with in the adult human prostate.

Purpose: We evaluated the International Prostate Symptom Score and correlated it with objective means of determining bladder outlet obstruction., Materials and Methods: Beginning in May 1996, 460 men 41 to 88 years old (mean age plus or minus standard deviation 60.4 +/- 9.4) were prospectively included in this study. Symptoms were evaluated using the International Prostate Symptom Score, and digital rectal examination, outpatient cystoscopy, prostate specific antigen determination and transrectal ultrasound were done. Urodynamic evaluation included uroflowmetry, filling cystometry and pressure flow study., Results: Linear regression was done to correlate scores with measurable parameters. We noted no correlation of the total, obstructive symptoms or irritative symptoms score with objective parameters, including the average and maximum flow rate, post-void residual urine, prostate size and Schäfer grade., Conclusions: Prostatic symptom scores are qualitative. Using them to quantify the degree of obstruction or evaluate therapy is questionable.

A system for computerised analysis of ultrasonographic prostate images (AUDEX=Automated Urologic Diagnostic EXpert system) for the detection of prostate carcinoma was developed. The ultimate goal is to develop a system that is reliable and non-observer dependent. Results of an earlier study with a small group were encouraging and this study describes the results of the computerised analysis in a larger group. Sixty-two patients who were scheduled to undergo a radical prostatectomy were prospectively analysed. The radical prostatectomy specimens were step-sectioned in the transverse plane, corresponding to the ultrasound pictures. Malignant regions identified by each study were quantified and compared by computer calculation. No correlation was observed between ultrasound analysis and pathology result. For the AUDEX analysis an overall sensitivity of 85% and a specificity of 18% with only a diagnostic accuracy of 57% was noticed when presence or absence of malignancy was evaluated by octant (total 496). When applying a cut-off value of 0.5 ml the numbers were 71%, 33% and 55%, respectively. Correlation was significantly better for the ventral octants. In this study the earlier results of our AUDEX system could not be confirmed. Although sensitivity was good, specificity and especially diagnostic accuracy were lower than expected. We have to conclude that the current settings are inappropriate for routine clinical use. Prostate Cancer and Prostatic Diseases (2001) 4, 56-62

Purpose: We investigated the effect of the alpha-blockers alfuzosin, terazosin and tamsulosin on urodynamic parameters after 6 months of therapy., Materials and Methods: Between February 1992 and June 1998, 163 patients with lower urinary tract symptoms suggestive of bladder outlet obstruction were treated with alfuzosin (60), terazosin (66) and tamsulosin (37). Patients were evaluated with urodynamic studies, including pressure flow analysis, before treatment and after 6 months of therapy. Initially, all patients were also assessed by the International Prostate Symptom Score questionnaire and measurement of urinary flow rate., Results: The majority of patients had no clear improvement in obstructive parameters, regardless of the alpha-blocker used, as urethral resistance factor and detrusor pressure maximum flow rate decreased by only 4 cm. H2O. There was a clear subjective and statistically significant decrease in International Prostate Symptom Score and quality of life scores of 6 and 2 points, respectively. No relevant statistical difference was noted among the effects of the 3 alpha-blockers on relieving symptoms or improving urodynamic parameters of obstruction., Conclusions: The alpha-blockers are effective for treating symptoms suggestive of bladder outlet obstruction in patients presenting with lower urinary tract symptoms but not for treating the obstruction.

Objective: To assess the prevalence of lower urinary tract symptoms (LUTS) in men and its influence on quality of life., Design: Questionnaire investigation., Methods: Recruitment of subjects was conducted in 1998 in the municipality of Boxmeer. Men in the age range between 40-79 years were sampled from the Municipality Basic Administration System. Data on LUTS, quality of life, and health care seeking behaviour were collected with a postal questionnaire. Severity of LUTS was evaluated with the Dutch translation of the seven items of the International Prostate Symptom Score (IPSS), to which 6 questions were added regarding micturition frequency, dribbling, difficulty to start micturition, painful micturition, decreased force of stream since the age of twenty, and how long one could wait before micturition from the moment urge was noticed. The female partners of the respondents were asked to answer the questions as well., Results: 1233 men completed the questionnaire, a response of 70%. One-fifth of all participants reported moderate to severe symptoms. Dribbling, reduced force of stream and urgency appeared to be the three most prevalent symptoms. The prevalence of LUTS increased with age: 10% of men aged 40-49 reported moderate to severe symptoms (IPSS > 7) compared with 44% of men over 70. Twenty-nine per cent of the men with severe LUTS reported poor disease specific quality of life, while another 28% of these men reported excellent disease specific quality of life. All men with mild symptoms reported excellent quality of life. Nine percent of all men consulted a doctor because of LUTS, with a mean delay of 10 months. The LUTS frequencies among the female partners equalled those among the responding men., Conclusion: LUTS were common among men over forty and among their female partners. The prevalence increases with age. Ageing of the population may lead to increased numbers of men experiencing LUTS and to concomittant medicalization costs. It is therefore of great importance to realise that the impact of symptoms on the reported quality of life was not pronounced.

Transurethral microwave thermotherapy (TUMT) has gained a firm place in the spectrum of therapeutic modalities for management of patients with lower urinary tract symptoms suggestive of bladder outflow obstruction. To achieve optimum results following TUMT, intense research focuses on appropriate patient selection, heat-tissue interactions, and modification of technical specifications. Results of TUMT are good to excellent for the majority of patients, but there is a non-negligible number of patients who respond poorly. The selection of favorable candidates for TUMT aims to improve the therapeutic results, and both clinical baseline parameters and intrinsic characteristics of the prostate (histologic composition and vasculature) may influence treatment outcome. TUMT achieves therapeutic response through coagulative necrosis of the hyperplastic tissue, but additional theories have been proposed recently, suggesting that TUMT may cause neural destruction and induce apoptosis. Individualization of the treatment is expected to offer the best results, and because the temperature achieved inside the prostate determines the actual parenchymal necrosis, thermal monitoring during treatment will permit application of microwave energy in a feedback mode. Various microwave devices differ in technical specifications (operating frequency, design of antenna, cooling system), and recently introduced software programs (high-energy protocols, heat-shock strategy, short-duration protocols) aim at better efficacy, providing a more patient-friendly procedure. TUMT has survived the "test of time" that other, initially promising, modalities have failed. What remains to be determined is the maximum benefit that patients and health systems can gain from such a technique.

Purpose: To assess the efficacy and durability of a new 30-minute algorithm for high-energy transurethral microwave thermotherapy (TUMT, Prostasoft 3.5) in the treatment of men with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia., Materials and Methods: A total of 167 men (mean age 67 years) with bothersome LUTS were treated with the new TUMT protocol. Evaluation included assessment of the short- and long-term objective and subjective outcome measures of this treatment., Results: The treatment is well tolerated. The International Prostate Symptom Score improved from a mean of 19.2 at baseline to 7.9 at 12 months after treatment. Maximum urinary flow improved from 8.9 to 16.4 mL/s at 12 months. Mean duration of catheterization was 16.1 days. Urodynamic evaluation showed a change from the obstructed to the nonminimally obstructed zone. There were no serious complications., Conclusion: High-energy TUMT using the new high-dose Prostasoft 3.5 protocol appears to be a safe, effective, and durable treatment. The faster procedure improves tolerance of the treatment. Subjective and objective improvements were significant and the treatment-related morbidity low.

Purpose: To evaluate the impact of high-energy transurethral microwave thermotherapy (TUMT) and transurethral prostatic resection (TURP) on quality of life (QoL) in patients with benign prostatic hyperplasia (BPH)., Materials and Methods: A total of 147 patients with BPH were randomized to receive either high-energy TUMT treatment (Prostasoft 2.5) or a TURP and were followed for 1 year. All patients completed a QoL questionnaire to assess perception of urinary difficulties, sexual function, daily activities, psychological well-being, social activities and improvement in QoL., Results: For almost all scales the standardized Cronbach's alpha was adequate. Between the various QoL scales there is a statistically significant correlation except for social well-being and sexual functions. There is also a significant correlation between the QoL scales and age, IPSS and Madsen. For the sexual functions there is only a correlation with age. A significant difference in improvement in favor of the TURP group was observed in general perception of urinary difficulties and activities of daily living. However, no difference between the groups was observed for the QoL scale measuring experienced improvement. The sexual function is not influenced by both treatment modalities. Both groups have a significant improvement in clinical outcome at all points of measurement. TURP has a better clinical outcome., Conclusion: Both TUMT and TURP have a significant positive effect on various aspects of QoL. In particular, perception of urinary difficulties and activities of daily living are positively influenced by both treatments. TURP, however, has a greater impact than high-energy TUMT.

Purpose: We investigated whether cell-kill modelling could be used as a mean for predicting the outcome of microwave thermotherapy for benign prostate hyperplasia (BPH)., Methods: The two models--Henriques' damage integral and Jung's compartment model--were implemented in a computer program. Real treatment data for 22 patients with BPH who were in chronic retention were used as input, including measured intraprostatic temperatures and microwave power. To test if modelling gives results that are consistent with actual observations, comparison with transrectal ultrasound (TRUS) measurements of the prostate volume before and after treatment was made. The sensitivity of the computer model for variations in the heat cytotoxicity and the temperature probe location in the adenoma was also tested., Results: The average TRUS volume reduction 3 months after treatment was 26 cc, whereas the corresponding cell kill calculation was 27 cc. The computer model appears to be rather insensitive to minor uncertainties in heat sensitivity and location of the intraprostatic reference temperature sensors., Conclusion: Cell-kill modelling appears to give results that are consistent with actual observations. The coagulated tissue volume is calculated in real time during the treatment, thereby providing an immediate prediction of the treatment outcome. By using cell-kill modelling, the endpoint of a treatment can be set individually; e.g., when a certain volume reduction has been achieved.

Transurethral microwave thermotherapy is being applied as a minimally invasive treatment for alleviating the symptoms of urinary outlet obstruction associated with benign prostatic hyperplasia. Treatment progress has traditionally been guided in its effective power by rectally and urethrally measured temperatures, whereas intraprostatic temperatures would be preferred for feedback purposes. A critical evaluation is presented of intraprostatic thermometry techniques that have been suggested, the techniques currently being used and investigated, and the problems that remain to be solved. Techniques for noninvasive temperature measurement and detecting tissue response during thermal therapy are discussed in more detail. Results presented in the literature have shown magnetic resonance imaging and ultrasonic imaging to be adequate thermometry modalities. For treatment monitoring of transurethral microwave thermotherapy, ultrasonic imaging is especially promising. Future research will indicate whether the promise evolves into a sound clinical technique.

Objectives: The long-term results of different laser technologies in the management of lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction (BOO) are not well known. We studied the durability of the effect of laser prostatectomy and tried to identify the factors predictive of treatment outcome., Methods: Between December 1992 and November 1996, 190 patients underwent laser prostatectomy because of LUTS suggestive of BOO. One hundred seven patients received visual laser ablation of the prostate (VLAP), 30 received contact laser vaporization (CLV), and 53 received interstitial laser coagulation (ILC). The baseline evaluation included the International Prostate Symptom Score (IPSS), uroflowmetry (maximum urinary flow rate), postvoid residual urine (PVR), prostate volume measurement, and urodynamic investigation. Patients were followed up until April 1999. Kaplan-Meier plots were constructed to calculate the risk of retreatment, and the log-rank test was used to evaluate the predictive value of clinical parameters for treatment failure., Results: The median follow-up in the VLAP group was 53 months; the retreatment rate was 14% (95% confidence interval [CI] 6% to 22%). The corresponding numbers for the CLV and ILC groups were 47 months and 14% (95% CI 1% to 26%) and 34 months and 41% (95% CI 23% to 60%), respectively. A high PVR and a high grade of obstruction in the VLAP group, and a younger age in the ILC group, were associated with increased retreatment risk., Conclusions: VLAP and CLV have a durable effect, as demonstrated by their low retreatment rate. ILC is a less aggressive procedure, at the expense of a high retreatment rate. Patient selection for VLAP can be based on the grade of obstruction and PVR.

This article reviews the available literature and data on high-energy transurethral microwave therapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS). TUMT is a safe, durable, (1-hour) procedure, without the need for anesthesia. Emphasis is made on the effect and mechanism of TUMT, the different devices available including different energy protocols, and accompanying clinical results.

Objective: To assess the efficacy of a new 30-min algorithm for high-energy transurethral microwave thermotherapy (TUMT, Prostasoft 3.5) in the treatment of men with lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia., Patients and Methods: A total of 108 men (mean age 66 years) with bothersome LUTS were treated with the new TUMT protocol. All patients were evaluated using a standard assessment at baseline, 6, 12, 26 and 52 weeks after TUMT. The evaluation included the assessment of objective and subjective outcome measures, with a urodynamic evaluation using pressure-flow analysis, and the occurrence of adverse events., Results: The treatment was well tolerated. In general, the International Prostate Symptom Score improved from a mean of 20.0 at baseline to a mean of 9.3 at 6 months after treatment. The maximum urinary flow improved from 9.4 mL/s to 14.6 mL/s at 6 months. The mean duration of catheterization was 17.9 days. The urodynamic evaluation showed a change from the obstructed to the equivocal zone on the Abrams-Griffith nomogram. There were no serious complications. Urgency and frequency were the most frequent side-effects after treatment; these all resolved within 3 months., Conclusion: High-energy TUMT using the new high-dose Prostasoft 3.5 protocol appears to be a safe and effective treatment. The faster procedure improves the tolerance of the treatment. The subjective and objective improvements were significant and the treatment-related morbidity low. A longer follow-up is needed to assess the durability of this new treatment protocol.

Purpose: To evaluate the tolerability of high-energy microwave thermotherapy in patients with benign prostatic hyperplasia (BPH) using two different treatment protocols (Prostasoft 2.5 and Prostasoft 3.5)., Materials and Methods: Pain and discomfort during treatment was evaluated using a visual analog scale in 39 patients undergoing 60-min Prostasoft 2.5 treatment and 41 patients undergoing 30-min Prostasoft 3.5 treatment. The duration of transurethral microwave thermotherapy (TUMT) 3.5 treatment is significantly shorter than TUMT 2.5 treatment., Results: The pain level is significantly higher at the beginning of the Prostasoft 3.5 treatment compared to the Prostasoft 2.5 treatment. The reported pain level becomes similar 10 min into treatment, and remains similar to the end of the 3.5 treatment (at 30 min), when the pain level returns to baseline. The 2.5 protocol patients experience continuously increasing pain until the end of the treatment at 60 min. One minute following termination of treatment, the pain level drops back to the baseline level. No correlation between the level of pain and the baseline subjective or objective voiding parameters was observed. A correlation is also absent between the pain level, age and catheterization time. There only seems to be a weak correlation between the pain level and TUMT energy in the Prostasoft 2.5 treatment group., Conclusions: Both TUMT 2.5 and TUMT 3.5 are well tolerated. Even though patients undergoing TUMT 3.5 treatment experience more discomfort initially, the ultimate discomfort is similar to the TUMT 2.5 treatment, during the first 30 min. Shortening of treatment time significantly reduces the pain and discomfort experienced by the patient. Pretreatment parameters are not predictors of the pain level experienced.

Objective: To investigate the value of three-dimensional contrast-enhanced power Doppler ultrasonography (3D-CE-PDU) in the diagnosis of prostate cancer and to compare 3D-CE-PDU with digital rectal examination (DRE), prostate-specific antigen (PSA) levels, grey-scale ultrasonography (GSU) and PDU., Patients and Methods: The study comprised 30 patients with localized prostate cancer scheduled to undergo radical prostatectomy and 29 with clinical BPH scheduled to undergo transurethral microwave thermotherapy. The 3D-CE-PDU examinations were carried out using 2.5 g of microbubble ultrasound contrast medium; the images were stored digitally to allow off-line analysis. All the reconstructed 3D images of the prostate were evaluated blindly in random order by two investigators (one expert and one novice). The images were scored according to asymmetry (0-2) and vessel distribution (0-3). Marked asymmetry (2) and/or a focal increase in vascularity (> 2) were considered as suspicious for prostate malignancy. Diagnostic predictions using the DRE, PSA level, GSU, PDU, 3D-CE-PDU and their combinations were investigated using receiver operating characteristic (ROC) curves., Results: True-positive and true-negative rates of the 3D-CE-PDU were 87% (26/30) and 79% (23/29), respectively, for the expert observer. The sensitivity of 3D-CE-PDU was higher than that of DRE, GSU and PDU, but not PSA level, and the specificity was lower, again except for PSA level. However, when compared with those of the other modalities in single-test evaluations, 3D-CE-PDU, and a combination of 3D-CE-PDU and PSA level, had the largest area under the ROC curve (0. 830 and 0.933, respectively). The diagnostic agreement between the examiners was 76% (Cohen kappa statistic, 0.5)., Conclusion: In this selected group of patients, 3D-CE-PDU alone was a better diagnostic tool than the DRE, PSA level, GSU or PDU alone. The most suitable diagnostic predictor for prostate cancer was a combination of 3D-CE-PDU and PSA level.

Purpose: We evaluated the efficacy of high energy transurethral microwave thermotherapy for treating urinary retention due to benign prostatic hyperplasia., Materials and Methods: Between October 1993 and March 1999, 41 patients with urinary retention were treated with high energy transurethral microwave thermotherapy. Initial evaluation consisted of a history, clinical examination, urethrocystoscopy, transrectal prostate ultrasonography and urodynamic investigation with a pressure flow study. Followup visits at 12, 26 and 52 weeks included International Prostate Symptom Score (I-PSS), uroflowmetry and post-void residual urine volume determination. At 26 weeks the urodynamic study was repeated. Kaplan-Meier plots were constructed to evaluate the risk of re-treatment adjusted for patients lost to followup., Results: At baseline median patient age was 74 years and median prostate size was 67 ml. Median 133 kJ. were administered. Nine patients underwent re-treatment and 11 were lost to followup. The re-treatment rate after 1 year was 25% (95% confidence interval 11 to 40). In good responders at 12, 26 and 52 weeks median maximal urine free flow was 15, 11 and 15 ml. per second, post-void residual urine volume was 61, 8 and 35 ml., and I-PSS was 7, 5 and 2, respectively. Quality of life (I-PSS question 8) was 1 at all visits., Conclusions: In patients with severe co-morbidity transurethral microwave thermotherapy is often the only alternative to an indwelling catheter with obvious quality of life advantages. High energy transurethral microwave thermotherapy appears to be effective in these patients.

Aims: Investigation of the histopathological changes in prostatectomy specimens of patients with prostate cancer after high intensity focused ultrasound (HIFU) and identification of immunohistochemical markers for tissue damage after HIFU treatment., Methods: Nine patients diagnosed with adenocarcinoma of the prostate underwent unilateral HIFU treatment seven to 12 days before radical prostatectomy. The prostatectomy specimens were analysed histologically. Immunohistochemical staining and electron microscopy were performed to characterise more subtle phenotypic changes., Results: All prostatectomy specimens revealed well circumscribed HIFU lesions at the dorsal side of the prostate lobe treated. Most epithelial glands in the centre of the HIFU lesions revealed signs of necrosis. Glands without apparently necrotic features were also situated in the HIFU lesions, raising the question of whether lethal destruction had occurred. This epithelium reacted with antibodies to pancytokeratin, prostate specific antigen (PSA), and Ki67, but did not express cytokeratin 8, which is indicative of severe cellular damage. Ultrastructural examination revealed disintegration of cellular membranes and cytoplasmic organelles consistent with cell necrosis. HIFU treatment was incomplete at the ventral, lateral, and dorsal sides of the prostate lobe treated., Conclusions: HIFU treatment induces a spectrum of morphological changes ranging from apparent light microscopic necrosis to more subtle ultrastructural cell damage. All HIFU lesions are marked by loss of cytokeratin 8. HIFU does not affect the whole area treated, leaving vital tissue at the ventral, lateral, and dorsal sides of the prostate.

Introduction: Adequate monitoring of volume and location of affected tissue might provide helpful information when performing localized ablative therapy for prostate cancer. We hypothesize that the change in blood flow patterns after therapy in comparison to the blood flow pattern prior to therapy can be used to locate and quantify the amount of affected tissue due to the therapy. We describe the use of three-dimensional contrast-enhanced power Doppler ultrasound (3D-CE-PDU) to determine its additive value to visualize the extent of tissue defects created by high-intensity focused ultrasound (HIFU) in correlation with the histopathology of the prostatectomy specimen., Materials and Methods: Nine patients with biopsy-proven localized prostate cancer, who gave informed consent, were included in the protocol. HIFU treatment was performed 1 week in advance of radical retropubic prostatectomy (RRP) as part of a protocol to study the value of HIFU treatment as local ablative therapy for clinical T(1-2)N(0)M(0) prostate carcinoma. 3D-CE-PDU was performed 1 day prior to unilateral HIFU treatment of the affected lobe on biopsy indication and 1 day before RRP using 2.5 g Levovist((R)) (Schering AG, Germany) microbubble ultrasound contrast agent and a Kretz((R)) Voluson 530D ultrasound scanner (Kretztechnik AG, Austria). Ultrasound data and pathology whole-mount sections were stored digitally to allow off-line processing. Human interpretations of HIFU measurements in three-dimensional ultrasound data were based on gray-scale information (local increase in gray level) in combination with power Doppler mode (absence of blood flow). Histopathological analysis of the whole-mount section revealed a broad band of hemorrhagic necrosis in the HIFU-treated area. Using both the ultrasound data and the pathology sections, the total volume of the prostate and of the HIFU-treated area was measured, and relative volumes were obtained., Results: Visual inspection of the three-dimensional reconstruction of contrast-enhanced Doppler measurements revealed the HIFU-affected prostate tissue by the absence of a blood flow pattern. Paired t tests of the relative HIFU volume indicated that Doppler results (mean 21.7%, SD +/-10.8%) differed from the pathology results (mean 32.6%, SD +/-16.0%), but a good correlation was found between the relative pathology HIFU volume (Pearson correlation r = 0.94, p<0.0015) and mean 3D-CE-PDU HIFU. Closer inspection of the pathology specimen revealed that the outer ring of the macroscopic hemorrhagic necrosis overestimated the actually dead tissue. On microscopy, the border of dead tissue appeared to be 1-2 mm inside the macroscopically identified red hemorrhagic band. 3D-CE-PDU HIFU volumes indicated by the single observers were not statistically different and correlated very well (Pearson correlation r = 0.98, p<0.001)., Conclusion: The results illustrate that 3D-CE-PDU is a promising method to determine the size of the defect of HIFU ablative therapy for prostate carcinoma. The absence of blood flow indicated by three-dimensional power Doppler ultrasound images reflects affected tissue after HIFU treatment, and volume measurements of these areas can quantify the amount of affected tissue.

Purpose: To determine the appropriate use of magnetic resonance (MR) imaging for preoperative staging of prostate cancer., Materials and Methods: Literature review was performed by using the principles of evidence-based medicine and medical technology assessment. A decision analytic model was used to compare (a) the strategy that radical prostatectomy is performed on the basis of clinical staging with (b) the strategy that extracapsular disease detected at MR imaging contraindicates radical prostatectomy in patients who were considered surgical candidates on the basis of clinical staging., Results: After review of the literature, expert panel opinion did not recommend MR staging. No studies in which therapeutic efficacy was addressed were found. The decision analytic model indicated that the strategy including MR staging decreased costs (MR imaging, $10,568; radical prostatectomy, $11,669) and resulted in almost equal life expectancy (MR imaging, 12.59 years; radical prostatectomy, 12.60 years) and quality-adjusted life-years ([QALYs] MR imaging, 12.53; radical prostatectomy, 12.52). Results of sensitivity analyses demonstrated that the MR strategy was both more effective and less costly if the prior probability of extracapsular disease was at least 39% when considering QALY and 50% when considering unadjusted life expectancy., Conclusion: It is not yet conclusively determined whether preoperative MR staging is appropriate, but results of decision analysis suggest that MR staging is cost-effective for men with moderate or high prior probability of extracapsular disease.

Objective: To present the results of laser prostatectomy on urodynamic parameters, and to address the role of pressure/flow studies as diagnostic tools for optimal selection of candidates for this treatment modality., Material and Methods: The world literature, available on Medline, presenting urodynamic parameters in patients subjected to laser prostatectomy was studied. We compared the data of different series, and when it was feasible from intrinsic features of a particular study, urodynamic results were plotted on the ICS Provisional Nomogram., Results: A general shift to a less obstructive status has been documented in all series, using different methods of data interpretation. No clear differences, in terms of elimination of obstruction, could be detected among different types of laser. Plotting the data on the ICS Provisional Nomogram, most series slide from the obstructed to the unobstructed zone. The observation that clearly obstructed groups accomplish the most impressive results, further emphasizes the value of urodynamics in the initial evaluation of benign prostatic hyperplasia patients by assisting in the appropriate choice of the therapeutic modality., Conclusions: Using the objective parameters of infravesical obstruction, laser prostatectomy has proved an effective treatment of benign prostatic hyperplasia. The role of pressure/flow studies in patient selection is justified, as this investigation permits identification of those cases who are going to have a direct benefit from a desobstructive procedure.

Objective: Little is known about risk factors for the development of benign prostatic hyperplasia (BPH). Recently, associations were observed between prostate cancer (CaP) risk and polymorphisms in the vitamin D receptor (VDR) gene and the androgen receptor (AR) gene. Since both receptors are relevant for prostate growth, the VDR and AR are also expected to be involved in the development of BPH. The objective of this study is to establish the relationship between the risk of BPH and a polymorphism in the number of CAG repeats in the AR gene and a TaqI restriction enzyme polymorphism in the VDR gene., Methods: For this study, 98 patients who had been treated for BPH-related complaints and 61 convenience controls (predominantly bladder cancer patients) were recruited from the outpatient clinic. DNA was isolated from peripheral blood, and genotyping was performed with PCR-based methods. Means as well as odds ratios (ORs) with 95% confidence intervals (CI) were calculated using SPSS software., Results: The mean number of CAG repeats in the AR gene in patients and controls was found to be similar: 21.8 (SD = 2.8) and 21.9 (SD = 2.9), respectively. In the subgroup of patients with a prostate volume of at least 50 cm(3), the mean number of repeats was 21.5 (SD = 2.6). The OR for BPH for individuals with homozygous presence of the VDR TaqI restriction fragment length polymorphism (RFLP) (tt) versus individuals with homozygous absence (TT) or heterozygotes (Tt) was found to be 1.0 (95% CI 0.4-2.4). For individuals with a prostate volume of at least 50 cm(3), the OR was 1.2 (95% CI 0.5-3. 2)., Conclusion: Unlike earlier observations in prostate cancer, we did not find an association between the CAG repeat polymorphism in the AR gene and the TaqI RFLP polymorphism in the VDR gene and the risk of BPH.

The objective of this study was to assess the intra- and inter-investigator variation in the analysis of pressure-flow studies that were performed in men with lower urinary tract symptoms. Two hospitals were involved in this study. In each hospital 100 PFS were selected. Photocopies of printouts of all PFS were analyzed manually by six experienced investigators, including determination of P(detQmax) and Q(max). Afterward, all 200 PFS were analyzed again in a different order. For each P(detQmax) and accompanying Q(max) the AG-number was calculated. With these AG numbers, the intra-investigator SD, the inter-investigator SD and the intra- and inter-investigator SD combined were calculated. The intra- and inter-investigator SD combined was 10.7. This implies that if one investigator analyzes a PFS once and determines an AG number of 40, another investigator may determine an AG number between 40 +/- 2. 77*10.7 = 10-70, using a 95% confidence interval. The inter-investigator SD was 10.0 and the intra-investigator SD was 3.7. The reproducibility of the manual analysis of urodynamic studies is moderate owing to a considerable intra- and inter- investigator variation. This is mostly caused by the substantial intra-investigator variation.

Introduction: Prostate cancer is the leading malignancy in men today and an increase in detected localized prostate cancers is expected in the years to come. Even though radical prostatectomy is an effective treatment, it is associated with a considerable morbidity in some cases and efforts are made to provide minimally invasive alternative treatment options with equal efficacy but fewer side effects., Methods: Cryosurgical ablation of the prostate (CSAP), brachytherapy, high-intensity focused ultrasound (HIFU) and radiofrequency interstitial tumor ablation (RITA) were evaluated after a literature review from a Medline Search (1966-1998). Furthermore, personal experience and latest data from the authors were taken into account., Results: All alternative treatments nowadays make use of sophisticated technology, including the latest ultrasound devices for exact planning and monitoring of treatment, leading to increased safety compared to treatments in the 1960s and 1970s. Five-year results of CSAP show a PSA <1 ng/ml in 60% of cases whereas brachytherapy is able to achieve PSA <1 ng/ml in 80% of cases in a selected group. Recent outcome data come close to results of radical prostatectomy series. HIFU and RITA are promising new technologies that proved to be able to induce extensive necrosis, but the follow-up is too short to determine their definite places in the treatment of prostate cancer., Conclusion: Two alternative treatment options for localized prostate carcinoma, CSAP and brachytherapy, have been studied with a sufficient number of patients and an adequate follow-up. The overall results of brachytherapy are favorable when compared to CSAP and are in the same range as the outcome after radical prostatectomy. HIFU and RITA are relatively new techniques based on sophisticated technology that are very promising at present, but a longer follow-up is mandatory.

The objective of this study was to assess the short-term test-retest variability of pressure-flow studies (PFS) in men with lower urinary tract symptoms (LUTS). By choosing a short interval between two consecutive PFS, but notably not performing two tests within a single session, both tests represent the same routine testing procedure. Eighty-nine patients with LUTS suggestive of bladder outlet obstruction or detrusor underactivity, who received PFS, were asked to undergo a second urodynamic evaluation within 4 weeks after the initial test. At both visits, specialized physicians performed the PFS. Obstruction was quantified using the Abrams-Griffiths number (AG number). Each patient was classified as obstructed, unobstructed, or equivocally obstructed according to the International Continence Society nomogram. As expected, no systematic difference was observed in AG number between the first and the second visit at the group level. There was, however, considerable variation at the individual level. The average within-patient standard deviation was 14 cm H(2)O. This finding shows that if a patient's AG number is 30 at the first visit, his true AG number can be any value between 30 +/- 1.96 * 14 = 3 to 57, owing to random variability alone. The average within-patient standard deviation did not differ significantly between sub-groups of obstruction and other variables such as patient age, symptom score, prostate volume, or residual volume. The variability appeared to increase slightly with an increased interval between visits. Of all patients, 39% changed at least one category of obstruction at the second visit and 3% changed from definitely obstructed to definitely unobstructed or vice versa. We conclude that PFS cannot stand the test of serving as a gold standard to identify bladder outlet obstruction in patients with LUTS.