Multiple Vesico-Urethral Biopsies Following Radical Prostatectomy: The Predictive Roles of TRUS, DRE, PSA and the Pathological Stage
Introduction
After radical prostatectomy, transrectal ultrasound (TRUS) of the vesico-urethral anastomosis is generally considered to be an accurate diagnostic procedure in detecting prostate cancer recurrence because it provides a precise evaluation of the normal and pathological prostatic fossa anatomy [1], [2]. Particularly in cases of low PSA levels or cranial disease in proximity of the bladder neck, a TRUS, despite being less specific, is considered more sensitive than a digital rectal examination (DRE) [3].
The clinical need to perform a TRUS biopsy of the vesico-urethral anastomosis before treatment, in the event of a PSA failure, is still under investigation [1], [2]. Moreover, the decision regarding local radiation therapy after a radical prostatectomy is generally taken without documentation of recurrent local disease [1]. One main concern is the relative inability of a TRUS and a TRUS biopsy to detect local recurrence with a PSA<1 ng/ml [4] and the need to wait for a subsequent PSA increase in order to obtain a biopsy-proven local recurrence before proceeding with radiotherapy [5], [6]. Until a positive biopsy has been determined, a time delay in performing salvage radiotherapy is considered dangerous [6]. Nevertheless, a positive biopsy seems to be a good prognostic factor in terms of response after radiotherapy [7]. Several investigators have produced better results when using external-beam radiation in patients with local prostate cancer recurrence documented by biopsies, the suggestion being to use radiation therapy only in cases of a positive biopsy [8], [9], [10].
Following a radical prostactectomy, the predictive role of a positive TRUS of the prostatic fossa or the PSA level or the pathological stage is still unclear, and data from literature are controversial. Some authors have shown that cancer recurrence detection by means of the biopsy of the anastomosis seems to be correlated only to TRUS findings [3], and others to PSA levels and the pathological stage at the time of a radical prostatectomy [11].
The aim of this study is to verify the diagnostic accuracy of a transrectal ultrasound (TRUS) in the detection of vesico-urethral anastomosis tumour recurrence via multiple biopsies (6–8 cores) according to TRUS, DRE findings and PSA levels, with special attention given to patients with a PSA level ≤ 0.5 ng/ml. A statistical model has been constructed to predict the recurrence detection probability of each parameter studied.
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Material and methods
Starting October 1997, 128 TRUS-guided prostatic fossa biopsies were carried out in 119 consecutive patients (median age ± S.D.: 67.9±5.7 years) who had a sustained serum elevation of PSA≥0.2 ng/ml (median PSA: 0.89 ng/ml) following a radical prostatectomy or a palpable abnormality in the anastomosis area. Serum PSA levels were measured by using a radio-immunoassay (Tandem-R, Hybritech, USA). DRE findings were considered abnormal if any mass, nodule, hardness or irregularity was noted in the
Results
Five patients underwent more than one biopsy session: results of the repeated biopsies were excluded from analysis because of the small patient group. In the 119 patients evaluated, the mean PSA at the time of the TRUS biopsies was 1.8±3.7 ng/ml (range 0.2–28.8 ng/ml). DRE was positive in 37 patients (31%) and TRUS-detected, suspicious lesions in 64 cases (54%). Biopsies revealed recurrent carcinoma in 50% of patients (60/119). The detection rates according to the DRE and TRUS findings are
Discussion
Since its introduction in the early 1980s, TRUS has developed its imaging capabilities right up till today’s most powerful ultrasound machines, encompassing new technological methods such as Colour Doppler, Power Doppler and three-dimensional imaging [1]. Thus, the ability to diagnose prostate cancer and prostate cancer recurrence in the prostatic fossa has become greater thanks to the parallel development of transrectal ultrasound (TRUS) and TRUS-guided prostate biopsies. Initially, Wasserman
Conclusions
TRUS and TRUS-biopsy with 6–8 cores are efficient tools in the detection of local recurrence after a radical prostatectomy, even with a PSA<0.5 ng/ml. TRUS hypo-echoic lesions were positive at biopsy in over 65% of the cases; on the contrary, 34% of local recurrence was not visible with a TRUS. The combination of TRUS and DRE findings seems to predict biopsy findings best. The bladder neck is the site where tumour relapse is less visible, while the lesion site with the highest positive
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