Screening for Prostate Cancer: Intermediate Outcome Measures and Active Surveillance

Prostate cancer is the most frequently diagnosed cancer in men in the Western world. The increasing use of PSA as a screening test for this disease has contributed to a marked increase in the number of newly diagnosed prostate cancers in countries where screening is prevalent. Whether screening actually influences prostate cancer mortality is still unclear. Regardless of the conclusions of ongoing trials on this question, it is likely that opportunistic screening will continue to be used. A confirmed positive effect of screening on the disease specific mortality would give a population based screening program a stronger scientific basis. The disputable performance of the PSA test, the high prevalence of the disease in older men, together with a high incidence-to mortality ratio have confronted the medical community and especially the urological world with new dilemmas. Until new predictors become available which are capable of only detecting the significant prostate cancers, the high incidence, the serious side effects of prostate cancer treatments, costs, and especially the ethical aspects oblige us to consider the disadvantages of the currently used screening tools for prostate cancer. Overdiagnosis is one of the main problems. Ideally, detection of insignificant cancers could be avoided, but that is not presently possible, and therefore a likely by-product of a PSA screening program will be the frequent diagnosis of insignificant cancers. This thesis focuses on active surveillance as a way out of the screening dilemma described above. Active surveillance manages selected men with prostate cancer expectantly with curative intent. These carefully selected men are actively observed in order to have the possibility to offer them deferred curative treatment once the tumour seems to progress. This thesis explores what kind of cancers are diagnosed by screening, how to subsequently risk-stratify those and what the best strategy is for active surveillance of a subset of these cancers

Laser endopyelotomy for a rare form of ureteral obstruction after kidney transplantation

Obstruction of the proximal ureter is a rare complication after renal transplantation. Two cases are described in which functional obstruction has been treated with laser endopyelotomy. This is a safe procedure and a successful result has been achieved

Non-iatrogenic nephro-pleural fistula in a child

Background: A fistula between kidney and pleura is a rare entity, particularly in children. Fistulation is mostly iatrogenic, following percutaneous nephrolithotomy and has a reported incidence of <1%. In the absence of recent renal surgery the diagnosis may be hampered by a lack of suspicion. However, in Case of pyelonephritis with ipsilateral pulmonary symptoms fistulation between kidney and pleura should be considered.We present a pediatric case of a nephro-pleural fistula due to chronic pyelonephritis, as well as a review of the literature. We highlight that the etiology of the fistula may impact the effectivity of the treatment. Conclusions: Surgery-related fistulas mostly heal spontaneously with optimal drainage of urine combined with antibiotic treatment. In contrast, pyelonephritis-related fistulas (most common xanthogranulomatous pyelonephritis) frequently require additional debridement by (partial) nephrectomy

End-fire versus side-fire:a randomized controlled study of transrectal ultrasound guided biopsies for prostate cancer detection

Objectives: To compare prostate cancer detection rates between end-fire and side-fire ultrasound guided prostate biopsy techniques. Methods: A prospective randomized controlled trial was performed in patients who underwent prostate biopsy between 2009 and 2014. Patients were randomly assigned to the end-fire or side fire biopsy groups and underwent transrectal ultrasound guided prostate biopsy. The overall prostate cancer detection rate was compared between the two probe configurations. Trial was registered at Clinical Trials.gov with identifier: NCT00851292. Results: A total of 730 patients were included and randomized, 371 patients underwent prostate biopsy with side-fire probe and 359 patients with the end-fire probe. Prostate cancer detection rates were 52.4% in the end fire group and 45.6% in the side fire group (p = .066). Conclusions: No significant difference was found in detection rate of prostate cancer between the end-fire and side-fire probe in transrectal ultrasound guided prostate biopsy, neither for detection rate of prostate cancer in the apex