Totale prostatektomie: geschiedenis en resultaten van een controversiele operatie

Rede, uitgesproken bij de aanvaarding van het ambt van gewoon Hoogleraar in de Urologie aan de Erasmus Universiteit Rotterdam, op 21 september 197

Screening, early detection, and treatment of prostate cancer: A European view

Powerful tests are now available for the detection of prostate cancer, both more frequently and at an earlier and usually more curable stage. In some countries of the world, mainly the United States and some European countries, serum prostate-specific antigen (PSA) and rectal examination-based screening is routinely applied to men at risk. In other countries, particularly in Northern Europe, routine application of screening procedures for prostate cancer is not accepted for a number of reasons: knowledge about the natural history of early lesions suggests that indiscriminate use of these tests will lead to overdiagnosis and overtreatment, information on the effectiveness of treatment from randomized trials is unavailable, and no evidence exists that early diagnosis and treatment will lead to an improvement of disease-related and overall mortality. In this article a number of critical and controversial issues of screening for prostate cancer are reviewed. This includes the risk of prostate cancer to patients, the efficacy and acceptability of the screening tests, the issue of overdiagnosis in relation to the natural history, evidence concerning the effectiveness of treatment, and the chances that early treatment may lead to an improvement of prostate cancer mortality. In relation to these points it is concluded that prostate cancer is a frequent cause of death in men and that at present the possibility of early diagnosis and treatment represents the only possibility of cure. The question whether cure is necessary in every identified case or in identifiable subgroups remains unanswered at this time. Although the individual positive predictive value of the screening tests is low, a combination offers higher positive predictive values that are in the range of 70–80%. With proper streamlining of the screening tests, it may be possible in the future to detect one cancer in 2.5–3.0 biopsies. The most efficient use of the screening tests in the general population still remains to be determined. Estimates related to the amount of overdiagnosis are made. Depending on the definition used, overdiagnosis with one round of screening for prostate cancer is probably in the range two to threefold. The effectiveness of available treatment modalities compared with delayed management has not been studied in a prospective randomized manner. There is, however, indirect evidence, especially relating to the long-term survival of grade 3 patients and to the long-term normalization of serum PSA values after radical prostatectomy, that at least this treatment is effective. In conclusion, the use of the screening tests cannot be withheld from symptomatic men and those who wish to be examined for the presence of prostate cancer. Application to the general population should depend, however, on the result of a prospective randomized study that shows that early detection and treatment will decrease prostate cancer mortality

Treatment of benign prostatic hyperplasia by transurethral ultrasound- guided laser-induced prostatectomy (TULIP): Effects on urodynamic parameters and symptoms

Objectives This prospective study was undertaken to evaluate the effects oftransurethral ultrasound-guided laser-induced prostatectomy (TULIP) on urodynamic, symptomatic, and prostate volume parameters as well as serum prostate-specific antigen. Methods The TULIP procedure was performed in 33 patients with benign prostatic hyperplasia with a mean age of 66 years. Patients were evaluated by pressure—flow studies, prostate volume measurement by transrectal ultrasound, and the American Urological Association (AUA) symptom score. Results At 3-month follow-up, laser prostatectomy has resulted in an increased maximum flow rate from 6.6±0.5 to 11.2±0.6 mL/s and in an objectively proven relief of the urodynamic obstruction, as is evident by a decrease of the average value of the urethral resistance parameter URA and the detrusor pressure at maximum flow rate from 38.3 ± 2.7 to 21.3 ± 1.3 cm water and from 62.7 ±4 to 38.9 ± 2.1 cm water, respectively. Symptomatic improvement is evident from a decrease in the AUA symptom score from 20.4 at baseline to 8.8 at 6-month follow-up. Although the total symptom score did not change significantly between 6 months and 1 year follow-up, the score of the symptom “weak stream” was significantly higher again at 12 months follow-up. Conclusions The TULIP procedure is a urodynamically and symptomatically effectivetreatment. Conclusions about the durability of this treatment modality should be made with reser

The value of screening tests in the detection of prostate cancer. Part II: Retrospective analysis of free/total prostate-specific analysis ratio, age-specific reference ranges, and PSA density

Objectives: The ratio between free and total prostate-specific antigen (PSA) in serum (F/T ratio) was shown to improve the specificity of total serum PSA for the detection of prostate carcinoma in selected populations. In this study, the value of the F/T ratio for screening of prostate cancer was compared with that of age-specific reference ranges for PSA and PSA density (PSAD) by a simulation experiment. Methods: In 1726 men between 55 and 76 years old, 67 prostate carcinomas were detected by application of digital rectal examination (DRE), transrectal ultrasonography (TRUS), and tota

The value of screening tests in the detection of prostate cancer. Part I: Results of a retrospective evaluation of 1726 men

Objectives: The ratio between free and total prostate-specific antigen (PSA) in serum (F/T ratio) was shown to improve the differentiation between prostate carcinoma and benign conditions in selected series of patients. In this study the F/T ratio was analyzed for its ability to improve the specificity of total serum PSA, digital rectal examination (DRE), and transrectal ultrasonography (TRUS) for the detection of prostate cancer in an unselected screening population of men identified in the Rotterdam popu

Natural history of benign prostatic hyperplasia: Appropriate case definition and estimation of its prevalence in the community

There is no consensus about a case definition of benign prostatic hyperplasia (BPH). In the present study, BPH prevalence rates were determined using various case definitions based on a combination of clinical parameters used to describe the properties of BPH: symptoms of prostatism, prostate volume increase, and bladder outflow obstruction. The aim of this study—in a community-based population of 502 men (55–74 years of age) without prostate cancer—was to determine the relative impact on prevalence rates of the inclusion of these different parameters (and of different cutoff values for these parameters) in a case definition of BPH. There is agreement that age is the dominant determinant of BPH. However, of 28 different case definitions that were formulated only eight gave a statistically significant increase in the prevalence of BPH with age. The highest overall prevalence of 19% (95% confidence interval [CI], 15–23%) occurred using the definition that combines a prostate volume >30 cm3 and an International Prostate Symptom Score (IPSS) >7. The lowest prevalence rate of 4.3% (95% CI, 2-6%) occurred using the definition that combines a prostate volume >30 cm3, an IPSS >7, a maximum flow rate 50 mL Thus, prevalence rates depend very much on the parameters used in a case definition. Follow-up will establish which men will eventually request a workup and treatment for BPH and will help determine the best clinical definition of BPH

Dependence of male voiding efficiency on age, bladder contractility and urethral resistance: development of a voiding efficiency nomogram

The influence of age, urethral resistance and bladder contractility on voiding efficiency was evaluated by pressure-flow studies in 138 men of a mean age of 60 years (range 18 to 86). From these studies the urethral resistance parameter was calculated and the maximum bladder contraction strength was determined. Premature fading of the bladder contraction was quantified by a bladder contraction strength decay factor. Voiding efficiency was expressed by the parameter of post-void residual urine volume as a percentage of the initial bladder volume. Multiple regression analysis showed that voiding efficiency depended significantly in descending order of importance on urethral resistance, maximum bladder contraction strength and bladder contraction strength decay factor. Patient age was not an independent factor. Maximum bladder contraction strength and bladder contraction strength decay factor were not correlated, suggesting that maximum bladder contraction strength and its decay constitute different properties of bladder contractile function. A voiding efficiency nomogram is proposed, making use of the values for maximum bladder contraction strength and urethral resistance in individual patients. Such a nomogram may have predictive value for the occurrence of acute retention but it must be tested prospectively