Faculty Bibliography

PURPOSE/OBJECTIVE:We determined whether 60 to 79-year-old men with a negative digital rectal examination and a serum prostate specific antigen (PSA) within age specific PSA reference ranges could safely forgo prostate biopsy. MATERIALS AND METHODS/METHODS:We reviewed the medical records of all 60 to 79-year-old men at the Brooklyn Veterans Administration Medical Center who had a PSA assay, digital rectal examination and subsequent prostate biopsy for an abnormal rectal examination and/or PSA greater than 4.0 ng./ml. from January 1991 through August 1995. We compared our results using the standard reference range of 0 to 4.0 ng./ml. with those obtained had we used any of 4 different age specific PSA reference ranges. RESULTS:We performed 1,280 prostate biopsies in 1,046 men with available PSA and digital rectal examination data. Using age specific PSA reference ranges 73 of 1,280 biopsies (5.7%) would have been avoided. Of those 73 avoided biopsies 15 (20.5%) had cancer that would have gone undetected and 9 of 15 (60%) undetected cancers had unfavorable histology. Results were not statistically significantly different among the 4 age specific PSA reference ranges. Regarding race, cancer detection rates were significantly higher for black compared with white men but there was no statistically significant difference for missed cancers or missed cancers with unfavorable histology. CONCLUSIONS:In contrast to previous reports of unfavorable histological characteristics in only 5% of missed cancers using age specific PSA reference ranges, 60% of missed cancers in our patients exhibited unfavorable histology. We conclude that age specific PSA reference ranges did not safely eliminate the need for prostate biopsy in our study population. In 60 to 79-year-old men with a negative digital rectal examination we continue to use PSA greater than 4.0 ng./ml. as an indication for prostate biopsy.

PURPOSE/OBJECTIVE:We analyzed current practice patterns and determined whether urologists are diagnosing and staging prostate cancer in accordance with one another and with available literature. MATERIALS AND METHODS/METHODS:An anonymous questionnaire was mailed to 1,500 randomly selected practicing American Urological Association members throughout the United States, categorized according to practice setting and decade of residency training completion. RESULTS:There were 624 respondents (41.6%). Annual routine prostate cancer detection is being aimed toward the right of the age spectrum. More than half of respondents use age specific prostate specific antigen (PSA), while fewer than half use PSA density in determining need for biopsy. The vast majority will perform radical prostatectomy on patients whose age suggests that they will not benefit from surgery. High PSA values and Gleason scores often are disregarded as independent precluding factors when deciding to perform radical prostatectomy. Computerized tomography and radionuclide bone imaging are used routinely far in excess of what the literature suggests is appropriate. Regardless of preoperative staging results, most urologists still perform lymphadenectomy with all radical prostatectomies. CONCLUSIONS:Discrepancies exist in practice patterns between urologists as well as inconsistencies in logic within individuals. There is little variation between individuals in different practice settings. Our results reflect the often confusing and conflicting data published during the last decade.

PURPOSE/OBJECTIVE:We describe the use of an alternative catheter for clot irrigation. MATERIALS AND METHODS/METHODS:Six patients with severe clot retention that could not be treated successfully with irrigation using large bore urethral catheters were subsequently treated with a fenestrated 28 to 32F Rusch red rubber rectal catheter. RESULTS:All clots were successfully evacuated. Cystoscopic evaluation the following day in 4 patients with hematuria confirmed the absence of clots. The other 2 patients did not undergo cystoscopy but continuous bladder irrigation was completely clear for the next 24 hours and the catheters were removed without further sequelae. CONCLUSIONS:Irrigation through a rectal tube can provide immediate relief of clot retention and consequently avoid emergency endoscopic intervention in the operating room.

PURPOSE: We analyzed practice and referral patterns of primary care practitioners regarding the diagnosis of prostate cancer, and the evaluation and treatment of voiding dysfunction. MATERIALS AND METHODS: An anonymous multiple-choice questionnaire was mailed to all primary care practitioners in Brooklyn, New York who were registered with the Medical Society of the State of New York. RESULTS: More than 25% of primary care practitioners begin performing digital rectal examination after patient age 55 years. Compared to prostate specific antigen (PSA) 59% of practitioners believe that digital rectal examination is more sensitive or that the tests are equal, or they do not know. In regard to PSA 11% of respondents begin testing after patient age 60 years, 11% evaluate PSA only if digital rectal examination is abnormal and greater than 3% never evaluate PSA. Approximately 45% of primary care practitioners indicated that PSA of greater than 4.0 ng./ml. signifies prostate cancer regardless of patient age, prostate size or prostatis and 50% think that digital rectal examination elevates PSA in a clinically significant way. Although 93.2% of respondents refer a patient to a urologist after palpating a prostatic nodule, only 51.1% refer for an area of induration. Of the 47.2% of respondents who attempt pharmacotherapy for voiding dysfunction with finasteride, terazosin or both 15% do not know the agent mechanisms of action. Of those prescribing finasteride 68.6% are not aware of its effects on serum PSA. Overall 66.5% of primary care practitioners are not familiar with the American Urological Association Symptom Index while only 15% of those attempting pharmacotherapy use the index as a diagnostic tool. CONCLUSIONS: Primary care practitioners might require further education in regard to the use of PSA, digital rectal examination and pharmacotherapy in voiding dysfunction. Consideration should be given to the establishment of guidelines for urological referral.

PURPOSE/OBJECTIVE:To help determine the etiology and most appropriate treatment regimen for hypergastrinemia, dysuria-hematuria and metabolic alkalosis following augmentation gastrocystoplasty. MATERIALS AND METHODS/METHODS:Two patients who presented with refractory metabolic alkalosis (1 with dysuria-hematuria) underwent extensive laboratory evaluation, complete upper gastrointestinal evaluation and intravesical pH probe placement. RESULTS:Both patients eventually required high dose oral potassium chloride supplementation. Bladder mucosal pH was not reflected by buffered urinary pH. Both patients demonstrated significant gastroesophageal reflux and diminished overall gastric acid output. CONCLUSIONS:Outpatient maintenance on potassium chloride supplementation may be warranted in select patients and appears to be preferable to histamine blockade or omeprazole. Postoperative screening esophagogastroscopy and an additional surgical maneuver might be indicated to prevent possible adverse sequelae of reflux esophagitis. Gastrocystoplasty may be an inappropriate operation in children with renal insufficiency who have not had metabolic acidosis.