Faculty Bibliography

PURPOSE: A prostate specific antigen velocity threshold of 0.75 ng/ml per year has commonly been used to distinguish men with prostate cancer from those with benign prostate conditions. In addition, a prostate specific antigen velocity greater than 2 ng/ml per year has been linked to an increased prostate cancer specific mortality rate after radical prostatectomy and after radiation therapy. However, both of these frequently cited thresholds were determined largely in groups of men with a prostate specific antigen greater than 4 ng/ml. MATERIALS AND METHODS: Of approximately 26,000 men who participated in a prostate cancer screening study 22,019 had a prostate specific antigen of 4 ng/ml or less. Of these men 501 were diagnosed with prostate cancer and had sufficient data for a prostate specific antigen velocity calculation. We performed univariate and multivariate analyses to compare cancer detection rates and performance characteristics using various prostate specific antigen velocity thresholds in these men. RESULTS: In men with a prostate specific antigen less than 4 ng/ml, a prostate specific antigen velocity threshold of 0.4 ng/ml per year was most useful for recommending prostate biopsy. Overall prostate cancer was diagnosed in 223 (2%) men with a prostate specific antigen velocity less than 0.4 ng/ml per year compared to 278 (13%) men with a prostate specific antigen velocity greater than 0.4 ng/ml per year (p <0.0001). On multivariate analysis a prostate specific antigen velocity greater than 0.4 ng/ml per year was a stronger independent predictor of prostate cancer diagnosis than age, race or a family history of prostate cancer. CONCLUSIONS: The traditional prostate specific antigen threshold of 0.75 ng/ml per year was determined largely in men with a total prostate specific antigen of 4 to 10 ng/ml. Prostate specific antigen velocity thresholds in the range of 0.4 ng/ml per year should be used to help guide the need for biopsy in men with a total prostate specific antigen less than 4 ng/ml.

OBJECTIVES: To examine clinical and pathologic features and postoperative survival outcomes of men with prostate cancer detected by digital rectal examination (DRE) alone, elevated prostate-specific antigen (PSA) level alone, or abnormalities in both. METHODS: From 1989 to 2001, approximately 36,000 men participated in a prostate cancer screening study. We recommended biopsy for a PSA level greater than 4.0 ng/mL (until 1995) or greater than 2.5 ng/mL (after 1995) or DRE findings suspicious for cancer. The clinical and pathologic features were compared between patients with cancer detected by DRE alone and those with cancer detected by an elevated PSA level, regardless of DRE findings. We also evaluated progression-free survival, overall survival, and cancer-specific survival. RESULTS: Overall 303 men were diagnosed with prostate cancer by DRE alone, 1426 because of PSA level alone, and 504 by abnormal results on both tests. Of the cancers detected by DRE alone, 60 (20%) were non-organ-confined and 56 (20%) had a Gleason score of 7 or higher. Prostate cancers detected because of abnormalities in both PSA level and DRE results were significantly more likely to have adverse pathologic features, as well as lower rates of progression-free survival, overall survival, and cancer-specific survival than those detected by either test alone (all P <0.0001). CONCLUSIONS: A substantial proportion of prostate cancers detected by DRE at PSA levels less than 4 ng/mL have features associated with clinically aggressive tumors. The omission of DRE from screening protocols might compromise treatment outcomes because many of the cancers detected by DRE alone are potentially curable but may have worse outcomes by the time PSA also reaches a higher level.

PURPOSE: Although the use of stents after ureteroscopy has been studied extensively, relatively little has been published about stent placement before complicated ureteroscopic procedures. In this study, we examined our experience with stent placement before ureteroscopic management of renal and ureteral stone disease. PATIENTS AND METHODS: A total of 90 patients underwent ureteroscopic surgery on 115 renal units by a single surgeon from 2001 to 2006. All patients had documented follow-up with imaging either by CT or intravenous urography (IVU) with tomography. Patients were classified into two groups depending on whether they had a stent placed before ureteroscopy. Baseline characteristics, operative indications for stent placement, stone-free rates, and complications were compared between groups. RESULTS: Baseline characteristics were similar between the groups. The majority of patients received stents before stone management because of technical considerations during surgery (17/36, 47%) or infection (13/36, 37%). Strict stone-free rates after ureteroscopic treatment were 47% in the 79 procedures without previous stents, compared with 67% in the 36 procedures with prestenting (P < 0.05). Including small fragments (2 mm or smaller), stone-free rates improved to 54% v 78%, respectively (P < 0.02). Complications were not significantly different in the two groups (P = 0.70). CONCLUSION: Although routine stent placement is not necessary before all ureteroscopic procedures, we demonstrate that it is associated with good stone-free rates and few complications. In this retrospective cohort, prestenting was associated with significantly higher stone-free rates. Prestenting should be considered in challenging cases.

For more than two decades, open radical prostatectomy has been considered the gold standard for the surgical management of prostate cancer. More recently, however, laparoscopic and now robotic approaches to radical prostatectomy have become increasingly popular. It is unclear whether these techniques are associated with any material advantage with regard to short-term convalescence. In addition, the high positive surgical margin rates reported with robotic prostatectomy are concerning, particularly early in the learning curve. Additional experience with these methods and long-term follow-up data are necessary to determine whether the cancer control and functional outcomes meet the standards of open radical prostatectomy.

OBJECTIVES: Since the initiation of prostate-specific antigen (PSA) screening, the progression-free survival (PFS) rates after radical prostatectomy have markedly improved. However, few studies have evaluated whether PFS has improved for stage and grade-matched patients. Our objective was to examine differences in PFS after radical prostatectomy between the pre-PSA era (before 1992) and the PSA era, controlling for tumor stage and grade. METHODS: From 1983 to 2003, 3456 men underwent radical prostatectomy by one surgeon. The 10-year PFS rates were calculated for each era and stratified by pathologic tumor stage and grade. Kaplan-Meier curves were generated to show biochemical PFS over time. RESULTS: The proportion of patients with pathologically organ-confined disease increased from 64% to 69%, consistent with stage migration. The PFS rate in the PSA era was 87%, 63%, 58%, and 31% versus 71%, 63%, 47%, and 19% in the pre-PSA era for Stage pT2R0, pT3R0, pT2-T3R1, and pT3c/N1 disease, respectively. The PFS rate stratified by Gleason grade in the PSA era was 84%, 63%, and 37% versus 66%, 49%, and 32% in the pre-PSA era for Gleason grade less than 7, 7, and 8 to 10, respectively. The 10-year PFS rate for organ-confined disease improved from 70% in the pre-PSA era to 86% in the PSA era. CONCLUSIONS: Patients treated with radical prostatectomy in the PSA era have improved survival outcomes when controlling for pathologic stage and grade. This is likely attributed to the earlier detection of cancer through PSA screening, better identification of patients amenable to curative therapy, and the effects of lead-time bias.

PURPOSE: There are numerous reports on the results of watchful waiting or active monitoring protocols for men with low volume, biopsy Gleason grade 6 or less prostate cancer. When counseling patients with low grade prostate cancer about treatment options, it is useful to know the results of surgical treatment in this population. MATERIALS AND METHODS: In a contemporary radical prostatectomy series there were 455 patients with biopsy Gleason grade 3 + 3 prostate cancer and information on the number of positive biopsy cores. Of these men 292 had low volume disease on the basis of 2 or fewer positive cores. RESULTS: Overall 245 of 292 men (84%) with low volume Gleason 3 + 3 prostate cancer on biopsy had organ confined disease. The Gleason score in the prostatectomy specimen was 7 or greater in 78 men (27%), 25 (8%) had extracapsular tumor extension and 29 (10%) had positive surgical margins. In these patients preoperative variables were not reliable predictors of adverse pathological features. CONCLUSIONS: More than a third of Gleason 3 + 3 tumors on biopsy were upgraded in the radical prostatectomy specimen or had other adverse pathological features. Our results suggest that low volume Gleason 3 + 3 prostate cancer is frequently under staged, and that immediate therapy with radical prostatectomy is associated with favorable outcomes.

Active monitoring strategies recently have received attention as possible treatment options for men with low-risk prostate cancer who have a life expectancy of more than 10 years. However, no current criteria sufficiently predict outcomes for individuals with clinically localized disease and an otherwise long life expectancy who undergo either immediate or delayed treatment, or no treatment. This article describes the available evidence regarding treatment outcomes in men with low-risk prostate cancer and presents the case for immediate active treatment.

PURPOSE: We quantified the rates of over and under diagnosis of prostate cancer in 2 large patient cohorts during the last 15 years. MATERIALS AND METHODS: A total of 2,126 men with clinical stage T1c prostate cancer were treated with radical prostatectomy during 1 of the 3 periods 1989 to 1995, 1995 to 2001 and 2001 to 2005. The respective proportions of men with a tumor that met our criteria for over diagnosis (0.5 cm3 or less, confined to the prostate with clear surgical margins and no Gleason pattern 4 or 5) and under diagnosis (nonorgan confined, pathological stage T3 or greater, or positive surgical margins) were examined. RESULTS: The proportion of men with an over diagnosed tumor was 1.3% to 7.1%. The proportion with prostate cancer that was under diagnosed was 25% to 30%. An ancillary finding was that decreasing the prostate specific antigen threshold for biopsy from 4.0 to 2.5 ng/ml in the screened population resulted in a lower rate of under diagnosis from 30% to 26%, a higher rate of over diagnosis from 1.3% to 7.1% and an increase in the 5-year progression-free survival rate from 85% to 92%. Men who were 55 years or younger were significantly more likely to meet our criteria for over diagnosed cancer. CONCLUSIONS: Under diagnosis of prostate cancer continues to occur more frequently than over diagnosis. Lowering the prostate specific antigen threshold for recommending biopsy to 2.5 ng/ml resulted in a lower rate of under diagnosis and a higher progression-free survival rate.