Prostate Cancer

. 2016 Jan;8(Suppl 1):S53–S73.

Prostate Cancer

PMCID: PMC4850759

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostatic cancer current concepts on therapy

Lennart Andersson

Department of Urology, Karolinska Hospital, Stockholm, Sweden

The main indication for endocrine treatment, androgen deprivation, is disseminated prostate cancer. Estrogens have been largely abandoned due to their cardiovascular toxicity. Orchidectomy is preferable. Androgenic drugs, like cyproterone acetate, medroxyprogesterone acetate and flutamide, are less cardiotoxic than estrogens but even less effective in the long-term cancer control. Flutamide does not decrease serum testosterone and potency is usually preserved, but the anti-cancer effect is less reliable. LHRH-agonists resemble orchidectomy in their action. Ketoconazole gives rapid and complete androgen deprivation but is potentially toxic.

If there is no indication of metastatic spread, other treatment modalities with the aim of tumour sterilization may be assayed, radical surgery or radiotherapy. Radical prostatectomy was previously hampered by the potential hazards, incontinence, impotence etc. With nerve-sparing technique, potency can often be preserved, especially in small tumours. Incontinence is a rare complication. Extensive TUR, followed by laser coagulation of the capsule and adjacent tissues appears efficient to treat local cancer but needs longer observation for final evaluation.

Radiotherapy is less trying in the patient and usually preserves potency. Surgery seems slightly superior to radiotherapy with respect to long-term disease-free survival. Interstitial radiation therapy enables larger radiation dosage in the prostate than with external radiation and has less complications. Long-term effect of external and interstitial radiation seems approximately equal.

Management of clinically insignificant cancer, TO or stage A, will be discussed.

Presented at the: 5^th Saudi Urological Conference King Fahd Military Medical Complex 22-23 March 1989

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostate cancer: 10 years experience in Riyadh armed forces hospital

K. Al Otaibi, A. Al Jetaily, M. Said, M. Abomelha, M. Kourah, O. Koreich

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

In the Saudi Cancer publications, we have not found any studies about prostate cancer. In the Armed Forces Hospital, Riyadh, 37 prostate cancers were registered and 34 of these were diagnosed as clinical manifested prostate CA, whilst 3 cases were found as incidental prostate CA. The clinical incidence in our series is 0.09%. The annual and geographical distribution is demonstrated and a rank order amongst the urological CA patients is shown.

From the 37 patients with prostate CA, 9 cases were diagnosed to have poorly differentiated prostate CA (5 had metastasis), 15 cases had moderately differentiated prostate CA (10 with metastasis), and 12 cases had well differentiated prostate CA (8 cases had metastasis).

This paper discusses the Riyadh Armed Forces Hospital Experience in diagnosis and management, and shows the outcome of our cases.

Presented at the: 5^th Saudi Urological Conference King Fahd Military Medical Complex 22-23 March 1989

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Comparison of total and partial androgen blockade in treatment of advanced prostatic carcinoma

Harald Schulze, Theodor Senge

Department of Urology, University of Bochum, The Westfalische Prostatakarzinom Study Group, Herne, Germany

It has been proposed that early treatment of patients with advanced prostatic carcinoma by means of surgical or medical castration when combined with a direct antiandrogen will result in a more complete form of androgen blockade, thereby increasing response and survival rate when compared to orchiectomy alone. In order to evaluate this statement objectively we initiated a prospective and randomized multicenter study. Patients with newly diagnosed, previously untreated advanced prostatic carcinoma were randomly distributed to one of the following treatment groups: I. Orchiectomy plus antiandrogen Flutamide (3 × 250 mg p.o./day); II. Depot LHRH-analog Zoladex (3.6 mg s.c./4 weeks) plus Flutamide; III. Orchiectomy alone; IV. Zoladex alone. Treatment modalities in groups I and II represent total androgen blockade, treatment in groups III and IV partial androgen blockade. In the follow up patients are evaluated every 12 weeks according to the NPCTG criteria. 113 patients have been included in this study (grp. I 32 pts.; grp. II 30 pts.; grp. III 28 pts.; grp. IV 23 pts.). The initial response rate in grps. I and II was 90%, in grps. III and IV 86%. Progression rate during the first year of treatment in grps. I and II was 26%, in grps. III and IV 31%. Statistic analyses by survival curves up so far do not show significant differences between complete and partial androgen blockade. An update of our results will be presented.

Presented at the: 5^th Saudi Urological Conference King Fahd Military Medical Complex 22-23 March 1989

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Fine needle aspiration vs tru-cut biopsy of the prostate

Walter Michel, Helmut Birzele

Department of Urological, Knappschafskrankenhaus, Bottrop Osterfelder Str., Bottrop, Germany

Cytological examination of fine needle aspiration specimen of the prostate are compared to histological examinations of tru-cut biopsies. Of the 34 patients in whom fine needle aspiration was done, cytological examination was possible in 31. In 30 of these cases a simultaneous core biopsy was carried out. Histological examination after TUR or radical prostatectomy was additionally available in 13 cases.

Cytological diagnosis was correct in 28 of 31 patients, of whom 14 had prostatic cancer. In 7 of the 14 patients with carcinoma of the prostate cytological grading did not correspond to histological grading by core biopsy. From these cases core biopsy was correct in one and cytology was correct in three patients as proven by TUR or radical prostatectomy. There was only one false negative cytology in a patient who had also a false negative core biopsy previously. Two false positive cytologies were in an 84 year-old man with elevated PSA and obstructive prostatic enlargement; TUR was refused. In one case cytological examination of fine needle aspiration showed poorly differentiated cancer which could not be demonstrated even by repeated core biopsy. Cytological diagnosis was proven to be correct after radical prostatectomy.

These data demonstrate that reliable results can be achieved with cytological examination of the prostate.

Presented at the: 5^th Saudi Urological Conference King Fahd Military Medical Complex 22-23 March 1989

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Lymphomatous and leukemic infiltration of the prostate

T. W. Callaway, J. Beecham, T. Mughal

Departments of Surgery, Pathology and Medicine, King Fahd National Guard Hospital, Riyadh, Saudi Arabia

A 72-year old Saudi male was admitted to hospital with urinary retention. Physical examination revealed a clinically benign prostate and transurethral resection was carried out. Histologic examination showed evidence of round cell infiltration. Subsequent hematologic investigation diagnosed malignancy of small lymphocytic cell type (chronic lymphocytic leukemia vs diffuse los grade non-Hodgkin's lymphoma).

Lymphoma or leukemia clinically manifesting as prostatic disease is a rate phenomenon. Lymphoma can occur primarily in the prostate, or the gland may be involved secondary to pre-existing lymphoma or leukemia. Symptomatic involvement of the prostate usually occurs in older men (mean=60 years). However, it may present with bladder neck obstruction as early as adolescence. Signs, symptoms, and endoscopic findings are usually those of benign obstructive disease. Pathologically, lymphomatous/leukemic infiltration may be confused with granulomatous prostatitis, chronic prostatitis, poorly differentiated adenocarcinoma, small cell undifferentiated (oat cell) carcinoma, or sarcoma. The entire spectrum of lymphoma and leukemia has been identified within prostate. Treatment is based on the grade and stage of the disease process. prognosis is usually poor regardless of age, stage, grade, or treatment.

Presented at the: 5^th Saudi Urological Conference King Fahd Military Medical Complex 22-23 March 1989

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostatic specific antigen, Dhahran health center experience

F. M. Ayyat

Urology Department, Saudi Aramco, Surgical Services Division, Dhahran, Saudi Arabia

We determined PSA concentration in 107 serum samples obtained from 92 patients with prostatic symptoms over a period of one year at Dhahran Health Center. Patients age ranged 39-92 years, the mean age is 60 years. 62 patients underwent T.U.R.P. with pre-operative PSA evaluation with a range of (0.1-23.6 ng/ml), with an average of 3.5 ng/ml, (normal range 0.4-4.0 ng/ml). All patients with BPH and a high PSA returned to normal within 4 weeks post-op. 5 patients underwent needle biopsy of the prostate because of a positive digital rectal examination, 3 were highly suggestive of cancer of the prostate and the PSA was supportive of the pathological findings, but the other 2 had BPH and their PSA was normal. One patient with cancer of the prostate, who underwent radical prostatectomy, was discovered to have a recurrence of the tumor by an elevated PSA several weeks before he had a positive bone scan and PSA returned to normal after treatment.

In conclusion, PSA has a wide range in our series with BPH. Patients with a high PSA should have more tissue submitted for pathology and should have PSA repeated within 4 weeks after resection and if it is still high, a needle biopsy of the prostate is recommended. 24 patients did have a normal digital rectal examination (DRE) of the prostate and a normal PSA, those with a high PSA should have a needle biopsy of the prostate. A normal PSA and normal DRE in patients over 40 years is reassuring for the patient and the physician and we think that screening for cancer of the prostate should be combined also with rectal ultrasonography of the prostate.

Presented at the: 6^th Saudi Urological Conference National Guard King Khalid Hospital - Jeddah 27-28 November 1991

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostate cancer

Thomas Stamey

Chief of Urology, Standford University, California, USA

Progression of prostate cancer is proportional to intracapsular cancer volume and Gleason grade. Cancer volume is best estimated by an algorithm that includes an ambulatory serum PSA, six systematic spatially separated biopsies under transrectal ultrasound guidance, and planimetric measurements of ultrasound cancer volume when the tumour is seen in the peripheral and central zones. Eighty percent of all prostate cancers are less than 0.5 cc in volume; in view of the median doubling time of four years for clinical stage A and B cancers, these tumours are too remote in time to achieve clinical significance and should not be treated.

Presented at the: 8^th Saudi Urological Conference King Fahd Military Medical Complex 9-10 November 1993

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Radical prostatectomy

Thomas Stamey

Chief of Urology, Standford University, California, USA

Cancers less than 6 cc in volume can usually be cured by radical prostatectomy provided the surgeon does not violate the fascial boundaries. Iatrogenic positive surgical margins are common at the apex, in the posterolateral neurovascular bundles, and at Denonvilliers’ fascia.

Surgical techniques to avoid positive surgical margins will be illustrated.

Presented at the: 8^th Saudi Urological Conference King Fahd Military Medical Complex 9-10 November 1993

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostate cancer: The Riyadh armed forces hospital experience

K. Al Otaibi, A. Al Jetaily, M. Said, M. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

During the last 15 years, over 4,000 malignant patients were treated in Riyadh Armed Forces Hospital.

Over 300 of these were urological malignancies and 17% of these were prostate neoplasm. This paper will discuss prostate cancer patients and their management in Riyadh Armed Forces Hospital, from both the urological and oncological aspects; the relevant lecture on this subject, and the geographical distribution throughout the Kingdom.

We will also look at the estimated annual cancer morbidity rate in the Kingdom, as well as clinical incidents of this disease.

Presented at the: 9^th Saudi Urology Conference King Fahad Hospital - Jeddah 14-16 November 1995

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostate cancer: A retrospective study

Waleed Al Khudair, Mostafa Mansi, Akram Fatthalla

Department of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

The incidence of prostate cancer has been on an increasing trend in the west and far east over the last two decades. There has been no solid studies to document the mode of presentation and the treatment modalities applied to the local population of Saudi Arabia. This study involves all patients diagnosed to have prostate cancer and admitted to the King Fahad National Guard Hospital during the period from October 1983 through June 1996. There were 74 patients including 5 non-Saudi patients. The age of Saudi patients at the time of diagnosis ranged between 50 and 105 years (mean 76.8 +/- 9.4 years). Twenty-one (30.4%) patients presented with non-urologic symptoms, and 31 (44.9%) patients already had a large fixed prostate on presentation. Bone scan was not done in 10 (14.5%) patients and was positive for evidence of wide spread bone metastases in 34 (49.3%) patients at the time of presentation. Serum PSA was more than 10 ngm/ml in 37 (53.6%) patients, including 7 patients with PSA more than 100 ngm/ml, and in 11 (15.9%) patients markers were not done. Diagnosis was made by transrectal biopsy in 3 patients, transperineal biopsy in 17, and transurethral biopsy in 27 patients. In 9 (13%) patients prostatic biopsy was not done and diagnosis was made by FNA of metastatic legions. Initial diagnosis and management was carried out by Urologists in only 44 (63.8%) patients and only 9 (13%) patients were referred from primary health care physicians. Management of these patients varied widely between no treatment and bilateral orchidectomy with only one radical prostatectomy done. This study shows that most of the patients with prostate cancer are diagnosed with an advanced stage of disease when little help can be offered. The role of primary health care physicians in the early diagnosis of the disease is emphasized.

Presented at the: 10^th Saudi Urology Conference King Fahad National Guard Hospital 26-28 November 1996

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Predictive parameters in screening for prostate cancer

K. M. Al Otaibi, T. Al Tartir, F. M. Trabulsi

Surgical Services Division, Dhahran Health Center, Saudi Aramco, Dhahran, Saudi Arabia

Purpose: We reviewed our approach in evaluating patients with a suspicion of prostate cancer.

Materials and Methods: A total of 385 patients underwent Transrectal Ultrasond (TRUS) and prostate biopsy for the possibility of prostate cancer. Digital rectal examination, PSA, TRUS and the prostate biopsies were evaluated.

Results: Of the 385 patients, 106 (27.5%) found to have prostate cancer, 17 (4%) with PIN, 92 (24%) with evidence of chronic prostatitis and 170 (44%) with BPH. Of the prostate cancer patients, 52 (49%) had normal rectal exam and 29 (27.4%) had normal TRUS. The majority (90%) presented with high PSA.

Conclusions: Normal Transrectal Examination (TRUS) and normal Digital Rectal Exam (DRE) do not exclude the presence of prostate cancer. Serum, PSA, TRUS and random prostate biopsies should be used as screening tools for prostate cancer.

Presented at the: 14^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 13-15 February 2001 (19-21 Dhu Al Qa’dah 1421)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Radical prostatectomy for prostate cancer 10 years experience in Saudi Aramco

K. Al Otaibi, F. Ayyat, M. Aljishi, M. Milad, K. Taheini, T. Zein

Department of Urology, Saudi Aramco, Dhahran, Saudi Arabia

Purpose: We assessed the radical prostatectomy outcome for prostate cancer in our institution for the last ten years.

Materials and Methods: From 1989 to 1998, a total of twenty patients underwent Radical Prostatectomy, for localized prostate cancer. Pathological staging and follow up were reviewed.

Results: Postoperative pathological staging showed 3 patients (14%) had +ve pelvic node (stage D1), 6 patients (28.6%) had +ve margin (stage C) and 12 patients (47.3%) were organ-confined cancer. The follow up for these patients showed 33.3% of the organ-confirmed prostate cancer developed recurrence. One patient with stage D1 died 6 years later with metastases and the other 2 patients, still alive on hormonal therapy with PSA <0.1. Positive margin (stage C) patients showed no evidence of recurrence.

Conclusion: Bilateral pelvic node dissection prior or Radical Prostatectomy is necessary for an accurate prostate cancer staging. Patients with stage C prostate cancer could be monitored conservatively with DRE and PSA.

Presented at the: 12^th Saudi Urology Conference Al Hada and Taif Armed Forces Hospitals Program 23-25 February 1999 (7-9 Dhu Al Qa’dah 1419)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Incidental adenocarcinoma of the prostate in Saudi Arabian undergoing prostatectomy for BPH

H. Al Zahrani, V. Onoura, N. Al Jawini, M. Al Turki, A. M. Koko, A. Mobed, F. Shepl, A. H. Kardar, E. Lindstedt, S. Kattan, T. Merdad, A. Peracha, M. Aslam, K. Hanash

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Background: Adenocarcinoma of the prostate is believed to be uncommon among Saudi Arabians with only 137 cases reported by the Saudi National Cancer Registry in 1994 and ranked as the 7^th cancer in males with a crude incidence rate of 4.9%.

Objective: To determine the incidence of adenocarcinoma of the prostate in the specimens from patients who underwent TURP or open prostatectomy for symptomatic BPH.

Materials and Methods: We retrospectively reviewed the charts of all patients who underwent prostatectomy for symptomatic BPH between 1990-1994 in 2 major hospitals in Riyadh, Saudi Arabia.

Results: A total of 519 patients underwent prostatectomy in the study period. The charts of 412 patients were adequate for the review. There were 330 Saudis and 81 non-Saudi Arabs and one European patient. The mean age was 73.3 years (range 53-96). DRE was benign in 354 patients (86%), abnormal in 25 patients (6%) and unclear in 33 (8%). PSA was introduced in 1994 and done in only 16 patients of the study group. Pre-operative prostatic biopsy ruled out adenocarcinoma prostate in 14 patients with abnormal DRE, PSA of both, TRUP was performed in 384 cases and 28 cases had open prostatectomy. Adenocarcinoma of the prostate was found in the prostatic specimen in only 10 patients.

Conclusions: Incidental (T1 a-b) adenocarcinoma of the Prostate among Saudi Arabians is low (3%) in comparison to the reports from USA, Italy and Japan. While this study gave some insight about the disease, a national screening program is recommended to know the magnitude in this country.

Presented at the: 12^th Saudi Urology Conference Al Hada and Taif Armed Forces Hospitals Program 23-25 February 1999 (7-9 Dhu Al Qa’dah 1419)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Biological determinants of failure to cure men with prostate cancer

Thomas A. Stamey

Department of Urology, Stanford University School of Medicine, Stanford, California, USA

Background: The recent increase in ability to diagnose prostatic adenocarcinoma has created a dilemma for treatment decisions. There are no widely accepted criteria for distinguishing those patients who would benefit most from definitive therapy. We have explored the hypothesis that a few selected morphologic variable may have a dominant influence on prostate cancer progression and should the prime target for preoperative patient evaluation and future research.

Methods: Radical prostatectomy specimens from 379 men underwent detailed quantitative analysis for 8 morphologic variable using previously standardized techniques. Cancer progression during long term follow-ups (median and mean >5 years) was defined as a serum PSA of 0.07 mg/ml and rising. Multivariate statistical analysis was used to test independent predictive values for each variable.

Findings: Cancer grade (Stanford Modified Gleason Scale) and cancer volume were highly predictive of failure. Substituting the standard Gleason score markedly reduced the predictive value of grading. Intraprostatic vascular invasion and lymp node metastates had less independent predictive value. Capsule penetration, seminal vesicle invasion, intraductal cancer and positive surgical margins were not independently significant. A predictive equation for individual patients which includes preoperative serum PSA and prostate size performed well on a new set of validation cases.

Interpretation: Prostate cancer grade (Stanford Scale) and cancer volumes are powerful independent indices of tumor progression, far surpassing other predictors except preoperative PSA. Attention should be directed at improving the accuracy of preoperative estimation of these predictors as a solution to treatment decision in prostatic adenocarcinoma.

Presented at the: 11^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 24-26 February 1998 (27-29 Shawwal 1418)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Carcinoma of the prostate: Experience with 90 Saudi patients

M. S. Abomelha, M. Al Shyarba, S. Orkubi, A. Al Jutaili, M. Said, K. Al Otaibi

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Between 1980 and 1997 a total of 90 Saudi patients with adenocarcinoma of the prostate were treated in the Department of Urology. Riyadh Armed Forces Hospital. The patient's age at presentation ranged from 55 to 102 years with a mean of 73 years. The main presenting symptoms were prostatism in 89%, retention of urine in 67%, loin pain with dilated upper tract in 23%, back pain in 19% and hematuria in 12%. DRE evaluation revealed hard prostate in 73%, firm in 11% suspicious in 4% and normal prostate in 11%. 8 cases (9%) were diagnosed incidentally. From the date the PSA is in use (mid 1991), all the 25 patients who had the test, had elevated PSA regardless of the DRE findings. Most of the patient presented with high stage and grade: 48% had T4, 41% T3 and 11% T2. Grade 3 was present in 39%, grade 2 in 41% and grade 1 in 20%. At the time of diagnosis 65% of the patients had distant metastasis. Follow up was possible in 65 patients (72%) with a range of 3-96 months and a mean of 25 months. All patients had hormonal treatment, but 3 who had radical radiotherapy. The overall outcome of followed up patients showed progression of the disease in 25%, stable in 41% and death in 34%. The one year, 3 years and 5 years patient survival rate was 85%, 74% and 69% respectively.

We conclude that prostatic carcinoma is not a common disease in Saudi Arabia. Saudi patients with carcinoma of prostate do present late with advanced stage. The place of radical treatment with this advanced presentation is limited. The hormonal and supportive treatment did achieve a reasonable survival.

Presented at the: 11^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 24-26 February 1998 (27-29 Shawwal 1418)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Radical prostatectomy: 7 year experience

I. Shoukry

Department of Urology, King Fahd Centre, Cairo University, Cairo, Egypt

Radical prostatectomy offers the best chance for cure for localized prostate carcinoma. Between December 1990 and June 1997, sixty patients with localized prostate carcinoma were treated with radical prostatectomy. Age of patients varied between 48 and 73 years. 25% of patients were more than 70 years of age.

Preoperative stage was T1 in 20 patients (31%, T2 in 35 (55%) and T3 in 9 patients (14%) Understaging was noted in 29% in T1 and T2 and 22% in T3. Positive lymph nodes were found in 5% in T1, 17% in T2 and 22% in T3. There was no postoperative mortality. The most important intraoperative complication was rectal injury, which occurred in 7% of cases, and only 2 cases required temporary colostomy. Postoperative continence was complete in 78% of cases, and 16T of cases had only mild stress incontinence during the day. Severe stress incontinence was present in only 5% of cases.

Technical points to improve postoperative continence will be discussed. Bladder neck contracture occurred in 16% of cases and was treated successfully with cold knife incision of the bladder neck. Radical prostatectomy is an operation with low morbidity and should be offered for cure of patients with localized prostate carcinoma.

Presented at the: 11^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 24-26 February 1998 (27-29 Shawwal 1418)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Incidence of prostate cancer in Saudi Aramco institution

K. M. Al Otaibi, T. Tartir, M. Feehan

Department of Urology, Saudi Aramco, Dhahran, Saudi Arabia

The incidence of prostate cancer in Saudi Arabia is not well known except for the reported cases to the Tumour Registry Department. We reviewed the incidence of Prostate Cancer in Saudi Aramco Institution for the last ten years. Since 1987, a total of 137 patients were diagnosed with Prostate Cancer, From 1987 to 1992 most of the patients presented with advanced Prostate Cancer, 65% with bone metastases (stage D2) and only 31% with Organ confined tumor (stage A1, B).

In 1993, Saudi Aramco established PSA test, Transrectal Ultrasond (TRUS) and prostate biopsy. In 1995, a PSA screening program was established for Saudi Aramco employees and their dependents. Since then we observed a decline in the incidence of bone metastases (stage D2) to the range of 33% to 47% and increase in the incidence of organ confined tumor up to the range of 53% to 60%.

Conclusion: Further studies are needed from the different provinces in Saudi Arabia to know more about the incidence of Prostate Cancer in the Saudi Arabia population. Early detection of Prostate Cancer with a PSA screening test and DRE could decreases the incidence of advanced Prostate Cancer and detect patients with localized cancer that can benefit from radical management.

Presented at the: 11^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 24-26 February 1998 (27-29 Shawwal 1418)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Quality of life and outcome after radical prostatectomy

C. W. Biermann

Urologische Universitatsklinik, Ruhr University Bochum, Herne, Germany

Introduction: During recent years evaluation of quality of life has become an important issue in clinical trials concerning cancer patients, including those with prostate cancer. Traditionally, performance or measurement outcomes have been limited to mortality, morbidity, and life expectancy. For our Medicare beneficiaries we want to know more, especially how well they can function and carry on the activities of daily life. In the future health care management including total quality management will be an important issue of outcome research. The assessment of quality of life (QOL) is more than the evaluation of treatment and disease related morbidity. QOL is a multidimensional construct, based on the patient experience of his or her total life situation. However, there still exists a considerable methodological problem regarding the development of optimal instruments and methods for presenting the results. Up to now there have been few studies measuring quality of life after radical prostatectomy using different instruments. In our quality of life trials we tried to develop a more specific instrument for localized prostate cancer according to the guidelines of the EORTC Study Group of Quality of Life.

Methods: Between 9/94 and 9/95, the data of 37 patients with non-metastatic prostate cancer were gathered for analysis. The patient underwent radical prostatectomy. First step was to evaluate the symptomatology of the patients by means of open interviews. One day preoperative (PO), the day before discharge (P1), and one year after surgery (P2), the patients received symptomatic and psychological questionnaires. The symptomatic questionnaire contained a six step symptom scale with 20 items. To evaluate the subjective well being, we selected the “Basler Befindlichkeitsbogen” (Basler Well Being Questionnaire) with the four dimensions: vitality vigilance, social extroversion and psychological balance. All measurements were evaluated by patients’ self-rating. Statistical analyses were performed sith SPS program (DOS-System).

Results: The urological symptomatology in patients with prostate cancer showed significant differences between preoperative and one year postoperative values, 14,7 and 25,0 respectively, within the range of 1-100. Comparing the psychological parameters, we found that all patients showed a strong decline of subjective well being, mostly in vigilance and social extroversion.

Conclusion: The present prospective pilot study indicates that there is no positive correlation between results in urological cancer surgery and the individual psychological parameters of the patient. The data of this prospective study were the basis to develop and EORTC-specific tumor module for prostate cancer according to the guidelines of the EORTC. The next step was to test this instruments in a retrospective trial. The data including the first prospective unpublished study measuring QOL before and after the operation are also presented.

Presented at the: 11^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 24-26 February 1998 (27-29 Shawwal 1418)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Role of trus, PSA and digital rectal examination in detection of prostate cancer

K. M. Al Otaibi, T. Tartir, R. San Miguel, F. Trabulsi

Department of Urology, Saudi Aramco, Dhahran, Saudi Arabia

Purpose: We studied the correlation between Transrectal-Ultrasound (TRUS), PSA, Digital Rectal Examination (DRE) and incidence of prostate cancer.

Materials and Methods: From January 1997 to October 1997, 178 patients underwent Transrectal Ultrasond (TRUS) for an evaluation of the prostate gland. 127 patients underwent prostate biopsy for the possibility of Prostate Cancer. PSA, DRE. TRUS and prostate biopsies were evaluated.

Results: Of the 127 patients, 21 (16.5%) had a +ve biopsy for Adenocarcinoma of Prostate and 15 (11.8%) the biopsies showed PIN (10 patients with high grade PIN). Of 55 patients with abnormal TRUS (hypoechoic lesion) and high PSA, 11 (27.5%) had +ve biopsy for Adenocarcinoma of Prostae. Of 62 patient with normal TRUS and high PSA, 12 (19.4%) had +ve biopsies for Adenocarcinoma of Prostate and in 12 (19.4%) the biopsies showed PIN.

Of 69 patients with PSA density >0.15, 54 (78.3%) showed –ve prostate biopsy. Of the 21 patients with Adenocarcinoma of Prostate, 18 (85.7%) with normal DRE and 4 (19%) PSA Density <0.15. Of 42 patients with % free PSA ratio <16%, 35 (83.3%) had –ve prostate biopsy. 40% of the prostate biopsies showed chronic inflammatory cells consistent with prostatitis.

Conclusion: Normal TRUS and rectal examination do not exclude prostate cancer. Only 27.5% of the hypoechoic lesion on TRUS turned out to be cancer. PSA, TRUS and prostate biopsies detect more prostate cancer in the early stages.

Presented at the: 11^th Saudi Urological Conference King Fahd Military Medical Complex - Dhahran 24-26 February 1998 (27-29 Shawwal 1418)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Is prostate cancer uncommon in Saudi Arabia? The influence of early screening program on the incidence of prostate cancer in Saudi Aramco

Khalid M. Al Otaibi

Urology Unit, Saudi Aramco Medical Services, Dhahran, Saudi Aramco, Saudi Arabia

Objective: The incidence of prostate cancer in Saudi Arabia has been reported to be low as well as one of the lowest in the world. The early screening program for prostate cancer and its long term effect have never been evaluated in Saudi Arabia. We reviewed the influence of the early screening program on the incidence of prostate cancer among Saudi men in Saudi Aramco community.

Methods: From 1987 to beginning of 2000, a total of 270 patients were diagnosed with prostate cancer in our medical institution. The clinical pattern, diagnostic methods, pathological staging as well as clinical staging were analyzed. The review was conducted for three different time periods. All factors contributed tot the diagnosis of prostate cancer were also evaluated. We compared our data with the Saudi National Registry Tumor (NRT) and a neighbor country data.

Results: Before the year of 1993, the majority of patients with prostate cancer presented with voiding problems or symptoms as a result of metastases. 68% of patients were found to have advanced prostate cancer (stage T4, N, M), and 32% classed as organ confined tumor (stage T1, T2). From 1994 to 1996, with the introduction of serum PSA and TRUS for Saudi men population, prostate cancer was found to be the 2^nd most common cancer in Saudi men, advanced prostate cancer decreased to 44% and organ confined tumor increased to 56%. From 1997 to 2000, with the establishment of screening program for prostate cancer for Saudi Aramco employees and their dependents, prostate cancer became the most common cancer among all Saudi men. The incidence of advanced prostate cancer decreased significantly to 27% and the organ confined tumor increased to 73%.

Conclusion: The study confirms the significance of the early screening program on the incidence of prostate cancer among the Saudi men population. We found substantial differences between the reported incidence of prostate cancer from the Saudi National Registry Tumor (NRT) and our reports. In our series there was a significant influence of the early screening program on the incidence and the nature of prostate cancer among all Saudi men. The introduction of prostatic specific antigen (PSA) test, transrectal ultrasound (TRUS) and prostate biopsy in our medical institution have made it possible to diagnose more and more Saudi men with prostate cancer and in an earlier stage. Prostate cancer is considered one of the leading causes of cancers among the Saudi men in our medical institution.

Presented at the: 16^th Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 2-4 March 2004 (11-13 Muharram 1425)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Prostate cancer in Saudi Arabia: A 6 years (997-2003) update

Hisham A. M. Mosli

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Purpose: To report the latest available information on data concerning prostate cancer in Saudi Arabia that occurred in the last 6 years from 1997 to 2003.

Methods: Several reports were studied and analyzed. Among those there was one report describing the PSA reference ranges in Saudi men, one report on diet as a risk factor, one interview indicating an increase in the incidence rate, and reports that indicate low cancer detection rates among a group of screened men using PSA, DRE and biopsy. The most recent National Cancer Registry (NCR) reveals no change in prostate cancer prevalence rate in the Kingdom of Saudi Arabia for the years 1997 and 1998. There was one published report describing low prostate cancer related mortality rate.

Results: Compilation of the available data confirm that prostate cancer is still of low incidence and mortality rates in Saudi Arabia.

Conclusions: PSA screening for BPH patients to exclude the presence of cancer and screening of men at high risk of developing prostate cancer may be justified. However, unless based upon sound scientific data to justify it, mass population PSA-screening of ageing asymptomatic men will be associated with economical, ethical and legal problems. With this latter practice, the natural history will be lost, and there will be an unwanted over-detection of cancer cases in whom the therapy will be unproven on the long run to further reduce an already low or unknown prostate cancer specific mortality rate.

Presented at the: 16^th Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 2-4 March 2004 (11-13 Muharram 1425)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Screening for prostate cancer

Baher Kamal, Saud Taha, Gaber Abdulfatah, Ahmed Bahnasy

Department of Urology, King Faisal University, Al Khobar, Saudi Arabia

A research project was carried out at King Faisal University from April 2002 through October 2003. The project entailed screening male Saudi outpatients above 45 years of age for prostatic ca. 1000 males were included in the study. All patients had PSA measurements together with DRE. TRUS and TRUS guided biopsies were performed whenever indicated. The normal age-specific values for PSA were determined and compared with the international figures. The incidence of prostatic cancer in Saudi males was determined in such a group and compared to age matched international figures.

Presented at the: 16^th Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 2-4 March 2004 (11-13 Muharram 1425)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Outcome of prostatic biopsies in patients with a PSA of 4-10 ng/ml and/or abnormal DRE at KFSHRC

Khalid Al Ghamdi, Hassan Al Zahrani, Said Kattan, Khalid Al Othman, Ali Bin Mahfooz, Muhammed Aslam, Alaa Mokhtar, Raouf Seyam, Kamal Hanash

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Introduction: Prostate cancer is the most common cancer among elderly males in the USA and Europe. Recent data demonstrated a cancer detection rate of 20%-30% for patients with a PSA between 4-10 ng/ml. It is generally perceived that there is a lower incidence of prostate cancer in Saudi Arabia. This study was conducted to determine the incidence of prostate cancer in patients with an abnormal DRE and PSA <4 or a PSA of 4-10 ng/ml at KFSHRC.

Materials and Methods: The charts of patients who had an ultrasound guided prostatic biopsy between January 1998 and March 2003 were reviewed retrospectively. The inclusion criteria for the study were all patients who had a prostatic biopsy with an abnormal DRE and PSA of <4 or a PSA of 4-10 ng/ml regardless of the DRE status. The clinical, radiological and pathological reports were retrospectively reviewed.

Results: A total of 64 patients were reviewed. The mean age was 66 years, range (52-93). The reason for referral to the urology clinic was LUTS in 30 patients (46.8%), high PSA of 4-10 ng/ml in 12 patients (18.7%), abnormal DRE in 2 patients (3.2%) or a combination of LUTS, high PSA and DRE in 20 patients (31.3%). The indication for the biopsy was abnormal DRE in 9 patients (14%), high PSA in 38 patients (59.3%) or both in 17 patients (26.5%). Nine patients (14%) had a PSA of <4 ng/ml but abnormal DRE and 55 (86%) had a PSA of 4-10 ng/ml with or without abnormal DRE. TRUS showed a hypoechoic lesion in 15 cases (23.4%), hyperechoic in 5 cases (7.8%) and normal in the rest 44 cases. Sextant biopsy was done in 1 patient and 3 had a 4 quadrant biopsy. The histopathology showed prostate adenocarcinoma in 9 cases (14%), PIN in 2 cases (3%), BPH in 48 cases (75%) and BPH and prostatitis in 5 cases (8%). Of patients with PSA of <4 and abnormal DRE, 1 patient had prostate adenocarcinoma (11%) and one had a low PIN (11%). For patients with PSA of 4-10 ng/ml the cancer was diagnosed in 8 cases (14.4%) and 1 had high PIN (1.8%). Eight patients (12.5%) had complications of the procedure; 4 hematuria, 3 urosepsis and 2 hematospermia.

Conclusion: The prostate cancer detection rate in Saudi patients with a PSA < 4 but with abnormal DRE incidence of prostate cancer was 11.1%. For patients with PSA of 4-10 ng/ml it increased to 14.5%. This is below the international reported detection rate. It points to the need to conduct a national screening survey of a cross-sectional population to see if we truly have a lower incidence of prostate cancer compared to other nations.

Presented at the: 16^th Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 2-4 March 2004 (11-13 Muharram 1425)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Vascular-targeted photodynamic therapy for recurrent localized prostate cancer following radiation therapy

Mostafa Elhilali, John Trachtenberg, Armen Aprikian, Joseph Chin, Brian Wilson

Department of Surgery, McGill University, Montreal, Quebec, Canada

Phase I/II trials using the photosensitiser Tookad. The Prostate was illuminated with multiple transperineal probes positioned using specific treatment plan software and transrectal ultrasound (TRUS) probe with a brachytherapy grid. Response was determined using dynamic MRI, biopsy and PSA. 52 patients treated to determine optimum conditions and toxicity. With adequate drug and light doses, 50% negative biopsies were achieved at 6 months. MRI imaging adequately predicted outcome. Technical aspects, complications and future plans will be presented.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

High intensity focused ultrasound as a treatment modality for localized prostate cancer

Magdy M. Hassouna^1,2

¹Department of Urology, Toronto Western Hospital, University Health Network, ²University of Toronto, Ontario, Canada

Principle: High intensity focused ultrasound (HIFU) technology uses an ultrasound beam generated by high power transducer to generate heat. When the beam is focused on the prostatic tissues, it results into necrosis of the prostate without damaging the surrounding tissue.

Historical: The technology has been developed in late ‘80 in Europe. In 1993, HIFU was applied in clinical cases of human prostate cancer. In 1996 a European multicenter study on the efficacy and safety of the HIFU was published. In 2003 the Canadian Health Authority has approved HIFU as safe method for treating localized prostate cancer. HIFU is presently used to treat prostate cancer in Europe, Russia, Australia, Canada and South Korea.

Indications:

Localized prostatic cancer (T1–T2)
Not candidates for radical prostatectomy due to co-morbidity or high surgical risk patient
Alternative treatment to radiotherapy
Local recurrence following radical prostatectomy
Local recurrence following radiotherapy and/or brachytherapy.

Procedure: The prostate size should be within 30-35gm size, with an antero-posterior diameter <24 mm. Those patients with >35 gm size prostate are advised to have a TURP prior or concomitant with the HIFU treatment. The treatment is done under spinal or epidural anesthesia with IV sedation to minimize movement. It may last anywhere from 1 to 3 hours depending on the size of the prostate.

At the beginning of the procedure the patient is catheterized and positioned on his right side. After a small probe has been placed inside a liquid-filled latex balloon it is inserted into the rectum. This liquid keeps a constant temperature at the rectal wall throughout the treatment. The urologist maps the outline of the prostate treatment zone using the ultrasound component of the probe. Then 400 to 600 pulses of high intensity focused ultrasound are delivered to the prostate. This process effectively necroses the targeted tissue. The catheter remains post procedure for 7-14 days until the swelling diminishes.

Computer controlled firings result in precisely moving the focal point in order to ablate the whole prostate.

Immediate Post Treatment: Patients usually go home the same day as the treatment and in most cases resume a normal diet the same evening. Prophylactic antibiotics are prescribed after the procedure. Post procedure infections are not common with HIFU. Immediate post treatment complications include mild bleeding in the beginning of micturition, frequent and sometimes urgent micturition, type 1 or 2 urinary stress incontinence and elimination of necrotic debris. These complications are usually transient and self-limited.

Reported Adverse Effects: HIFU is a very safe procedure with no reported mortality and minimal morbidity. Data from the last 100 treatments in the Munich study of 315 HIFU treatments reported in 2000 provides the following incidence of adverse events:

graphic file with name UA-8-53-g001.jpg

Treatment Follow Up: PSA levels are performed initially and every 3 months post-HIFU. After 12 months, a biopsy is performed to confirm that the treatment has been successful. If the biopsy is negative and the PSA level is very low, the PSA only needs to be performed every 6 months.

If the PSA reading does not return to very low levels a repeat biopsy can be performed. If this biopsy shows any tumor (approximately 10% of the cases) a second HIFU session is conducted. If biopsies are negative but the PSA rises additional therapy may be needed.

Long-term Follow-up Results: A 5-year experience was reported on 146 consecutive T-1/T-2 prostate cancer patients with a PSA level of 15 ng/ml or less. The patients were treated with HIFU in Germany, between October 1997 and November 2002.

The median PSA nadir achieved after 3 months was 0.07 ng/ml and the median PSA level after a follow up of 22 months was 0.15 ng/ml. 93.4% of all patients had negative biopsies:

graphic file with name UA-8-53-g002.jpg

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Biochemical failure after definitive local therapy for clinically localized prostate cancer

Armen G. Aprikian^1,2

¹Division of Urology, Montreal General Hospital and Royal Victoria Hospital, ²Division of Urology at McGill University, Montreal, Québec, Canada

A detectable and rising prostate specific antigen (PSA) levels after radical prostatectomy or a rising PSA above the nadir after radiation therapy many represent a local failure, distant failure, or both. Determining the site or sites of failure is critical for selecting the appropriate salvage therapy. Nevertheless, although PSA failure precedes clinically evident failure by several years, determining the source of the biochemical failure is often not possible using currently available diagnostic studies. Selecting the optimal therapeutic approach may be guided by the initial clinical factors such as clinical stage, serum PSA, and biopsy Gleason score. In men having undergone radical prostatectomy, pathologic outcomes such as pathologic stage, prostatectomy Gleason score, and margin status provide additional prognostic information. In addition, PSA kinetics pre and post-treatment can provide significant information. For example, PSA velocity >2 ng/mL/year before treatment, an interval to PSA failure <2-3 years and a rapid PSA doubling time <3 after local therapy correlates with a significantly elevated risk for metastases and mortality, indicating that such cases are poor candidates for local-only salvage therapy. On the other hand, optimal candidates for local-only salvage therapy include men whose pretreatment PSA velocity was <2 ng/mL/year, interval to PSA failure exceeds 3 years, post treatment PSA doubling time is >12 months, and Gleason score < 8. In men with intermediate parameters, the salvage local therapy can be considered understanding that in the case of post-prostatectomy radiation therapy, that this should be undertaken before the PSA level passes 1 ng/ml. In case where systemic disease is suspected in an otherwise asymptomatic patient with undetectable metastases on imaging, then early hormonal therapy should be considered. However, one must keep in mind that most of these asymptomatic men will be on hormonal therapy for many years with the associated side effects. Methods to reduce the morbidity of hormonal therapy include intermittent therapy, anti-androgen monotherapy, and methods directed at bone health.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Laparoscopic radical prostatectomy for prostate cancer

Armen G. Aprikian^1,2

¹Division of Urology, Montreal General Hospital and Royal Victoria Hospital, ²Division of Urology at McGill University, Montreal, Québec, Canada

Over the past decade, laparoscopic radical prostatectomy (LRP) has gained significant popularity and widespread implementation at specialized centers worldwide. LRP represents a technically demanding procedure with some clinical advantages that include shorter convalescence and markedly lower operative blood loss. Long-term functional and oncological results are as yet immature, however early reports of positive surgical margin rates and biochemical control are very encouraging. Quality of life functional results of urinary and sexual function appear similar to those of open surgical series. Overall the current operative, oncological and functional results of laparoscopic radical prostatectomy appear to approximate those of open radical retropubic prostectomy. Nevertheless, longer follow up and more mature data are needed definitively to establish laparoscopic radical prostatectomy as an alternative to the open retropubic approach.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

The efficacy of radical retropubic prostatectomy has been well established in the management of localized prostate cancer

Raja B. Khauli, Sarah I. Sawah, Husam Al Qudah

Division of Urology, American University of Beirut Medical Center and the University of Massachusetts Medical Center, Beirut, Lebanon

Objective: Since 1997, we have applied Radical Retropubic Prostatectomy (RRP) to our patient population attempting a unilateral or bilateral nerve sparing for patients with clinically localized prostate cancer. We here present the data of our initial experience with this procedure.

Methods: 100 consecutive patients who underwent RRP and were potent preoperatively were followed postoperatively and analyzed for their sexual potency and continence rates. The same surgeon did all the surgeries using the Walsh RRP technique. The decision of which nerve to spare and which to resect, was based on preoperative parameters as well as intraoperative findings. Bilateral nerve sparing was performed on 61 patients, unilateral on 35 patients, and 4 patients had partial unilateral nerve sparing. The potency scale was defined as follows: Grade I = weak without response to injection, Grade II = weak but responds well to injection, Grade III = moderate with Sildenafil or Tadalafil, Grade IV = excellent with Sildenafil or Tadalafil, Grade V = excellent without treatment. The continence scale was defined as follows:

Continuous leakage
Light leakage
Occasional without stress
Stress incontinence
Complete dryness.

Results: Surgical margin positivity was noted in 15% of all cases (favorable outcome compared to the literature showing 12 – 45% positive surgical margins). Potency after RRP was preserved in 89% of patients who were able to have erections without the need for intracavernosal injection. Oral therapy only (with Sildenafil, Tadalafil and Vardenafil) was used in 63 (70.1%) of these patients with preserved potency. Bilateral nerve sparing had a 3.2-fold chance of excellent potency compared to unilateral nerve sparing (36.1% vs 11.4%, respectively, p < 0.001). Age < 60 years had a 2-fold likelihood of excellent potency compared to patients > 60 years (37.5% vs 19%, respectively, p < 0.001). Stage T1a-T2a did not show any significant difference in preservation of potency from stage T2b – T3a (1.5 fold, 29.1% vs 20%, respectively, p < 0.01). Continence after RRP revealed that 75% of patients were completely dry, 14% had mild stress incontinence, 9% had occasional leak and 2% had nighttime incontinence. Thus, this revealed that bilateral nerve-sparing RRP had a 1.5 fold likelihood of dryness compared to unilateral nerve sparing approach (88.5% vs 57.1%, respectively, p < 0.01). Also age < 60 years had a 1.2 fold likelihood of dryness compared to > 60 years (77.4% vs 66.7%, respectively, p < 0.01). Stage T1a-T2a showed no significant difference in preservation of continence from stage T2b-T3a (1.3 fold, 78.8% vs 60%, respectively, p < 0.01).

Conclusion: These data indicate that nerve-sparing RRP can be performed on the majority of clinically localized cancers without any adverse effect on the pathology and with relatively low surgical risk of margin positivity rate. The high likelihood of potency preservation with or without oral medications in this series should encourage surgeons to perform nerve sparing RRP more liberally. However, nerve-sparing RRP can only be applied after careful preoperative and intraoperative assessment of the cavernosal nerve for the possibility of adherence. The results of open RRP in recent series including our own, clearly indicates that this procedure remains the standard for treating localized prostate cancer.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Watchful waiting for prostate cancer: What are we watching and what are we waiting for?

Armen Aprikian^1,2

¹Division of Urology, Montreal General Hospital and Royal Victoria Hospital, ²Division of Urology, McGill University, Montreal, Quebec, Canada

Most men that develop prostate cancer do not die from it. However, prostate cancer is a very common disease and accounts for significant mortality. Furthermore, prostate cancer is currently diagnosed at an early stage where treatment is often curative but may have undesirable functional side effects. The objective is to identify those cancers that pose a clinical threat and treat aggressively while avoiding treatment in those cancers that pose little threat. To date, it is difficult to predict with certainty the biologic and clinical behavior of individual cancers. Factors employed currently to help decide on treatment versus observation include, age, comorbid status, histologic grade, extent of disease on biopsy, clinical, staging and serum PSA. In men believed to have insignificant cancer who are being observed, several clinical series have described the potential usefulness of PSA velocity and repeated periodic prostatic biopsies to help in the assessment of disease progression and trigger therapy within the window of opportunity of the disease being still organ-confined. However, virtually all of these tools have inherent variability and may not be reliable. Finally, although a recent randomized clinical trial has demonstrated improved survival in men undergoing radical prostatectomy as compared to observation, watchful waiting remains a management option in carefully selected men. The criteria for selection and the methods for surveillance remain controversial.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Incidental significant prostate cancer found in cystoprostatectomy specimens

Ashraf J. Abusamra, J. Izawa, M. Abdelhady, J. Chin

London Health Sciences Centers, University of Western Ontario, London, Ontario, Canada

Objective: To review the incidence rate, histopathological features, and outcome including disease specific survival rate of clinically significant incidental prostate cancer found at cystoprostatectomy (CPE) for bladder cancer, and to determine its impact on follow up.

Methods: Chart review of male patients who underwent CPE in our institution between 1987 and 2004 was done. Patients with preoperative diagnosis or suspicion of prostate cancer were excluded from further analysis. We identified those with incidental prostate adenocarcinoma in the CPE specimens.

Results: 218 men underwent CPE for bladder cancer in our institution between 1987 and 2004. 13 patients were excluded from the study due to preoperative diagnosis or suspicion of prostate cancer. Fifty-eight patients (28%) were found to have incidental prostate cancer. The mean follow up was 43 months (range: 6–149 months). Twenty percent of these prostate cancers had Gleason score ≥ 7 and two patients developed local and metastatic prostatic cancer recurrences.

Conclusions: Incidental prostate cancer is a relatively common finding in CPE specimens. With more than 20% of these considered clinically significant, radical prostatectomy as part of the CPE procedure seems essential, and vigilant follow up designed for both cancers, bladder and prostate, is mandatory.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

How does the prostate size really affect the biopsy Gleason score?

Ashraf J. Abusamra, J. Izawa, M. Abdelhady, A. Sener, A. Bella, N. Touma, D. Downey, M. Moussa, J. Chin

London Health Sciences Centers, University of Western Ontario, London, Ontario, Canada

Introduction: We analyzed our prostate cancer database to investigate the relationship between prostate size, biopsy Gleason score (bGS), and radical prostatectomy Gleason score (rpGS).

Methods: Our radical prostatectomy (RP) database from 2000-3 was studied. All transrectal ultrasound (TRUS) and biopsies were done by a single radiologist. The variables assessed included: prostate size on TRUS, bGS, and rpGS. We subdivided the data according to prostate sizes (< or ≥ 30g, < or ≥ 35g, and < or ≥ 40g), and bGS in three separate analyses using Chi square test.

Results: Complete data for eligible patients (pts) were available for 291 of 376 pts. Mean pt age was 61 years (44–75), and mean PSA 7.8 ng/ml (median 6.3). Median prostate volume in our data was 34.95cc (12.8–167.6). In our analyses using different prostate size cut offs, there was no effect on upgrading at rpGS; however, there was significant effect on downgrading, with smaller prostates showing more downgrading at rpGS.

Conclusions: Our analysis of the relationship between GS differences on biopsy and radical prostatectomy did not reveal a significant effect of prostate size on upgrading. This finding appears to contradict recent reports which have implicated larger prostate size in masking a higher Gleason score on biopsy. Sampling artifact results in rpGS downgrading in smaller prostates.

graphic file with name UA-8-53-g003.jpg

Our study may provide a new explanation and evidence for artifactual increase in higher grade tumors among men in the Finasteride arm of PCPT simply due to prostate size reduction.

Presented at the: 18^th Saudi Urological Conference King Abdulaziz University Hospital 20-23 February 2006 (21-24 Muharram 1427)

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Use of endoglin as a marker for diagnosis and prognosis of prostatic cancer

A. Elgamasy, M. Abo Elenin, A. Hassan, W. Elnaghy, R. Talaat, M. El Sharaby

Department of Urology, Tanta University, Tanta, Egypt

Aim of the Work: Quantitative estimation of serum endoglin levels in cases of prostatic cancer and benign prostatic hyperplasia to evaluate its role in the diagnosis and prognosis of cancer prostate.

Patients and Methods: This study included 70 patients and 12 normal control individuals. Measurement of PSA was performed for cases of cancer prostate and BPH, while measurement of endoglin was performed for all patients and control individuals. These cases were classified into 3 groups. Group I included 42 patients with cancer prostate, the criteria for diagnosis were digital rectal examination (DRE) of irregular abnormal hard nodule/nodules in the prostate or PSA > 4 ng/ml. The diagnosis was confirmed by TRUS biopsy. According to Gleason's score, these patients were further classified into Grade II and III. Group II included 28 patients with benign prostatic hyperplasia (BPH). Group III included 12 health men as control group. Serum CD 105 concentration was estimated by using human endoglin ELISA kit.

Results: For the group I (cancer prostate) and group II (BPH), mean age was 66.4 ± 4.9 and 63 ± 8.5 years respectively with no significant difference. However, there is a significant difference in PSA levels in group I (mean 32.4 ± 35.8 ng/ml) and group II (mean 2.84 ± 1.67 ng/ml). The mean values of CD 105 are 5.29, 2.12 and 0.15 ng/ml in group I, II and III respectively. The mean value of CD 105 in each group is significantly different from the other groups. In group I, the mean CD 105 level of grade III was 7.5 ng/ml and significantly higher than 4.89 ng/ml of grade II cancer prostate. There is a significant correlation between CD 105 levels and their PSA levels in cancer prostate group. After collecting the values of serum endoglin levels in cancer prostate and BPH cases and normal control groups, it was found that the cut-off level is 2.65 ng/ml for diagnosis of cancer prostate.

Conclusion: Endoglin (CD 105) has a critical role in the diagnosis and prognosis of cases of cancer prostate and it can be as a marker for these cases. However, further studies are recommended for evaluating its rule as a main diagnostic and prognostic marker for cases of cancer prostate.

Presented at the: 20^th Saudi Urological Conference King Fahad Hospital of the University - Tabuk 18-20 March 2008

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Free/total PSA ratio (<10%) can help in the prediction of extra-capsular extension of prostate cancer

A. Abdul-Rahman, T. Lane, D. Hanbury, G. Boustead, J. Adshead, T. Mc Nicholas

Department of Urology, Lister Hospital, Stevenage, UK

Objective: The indications for imaging prior to radical surgery for prostate cancer (in those with presenting PSA < 10) differs between surgical units with additional imaging often reserved for those with Gleason scores (GS) of ≥ 7. We examined a number of pre-operative parameters and the histopathology specimens to see whether any might select patients who would benefit from further pre-operative imaging.

Patients and Methods: We reviewed the pathological specimens of 35 consecutive patients undergoing radical prostatectomy during a 12 month period at a single institution. Gleason Score (GS), and the extra-capsular extension were detected and correlated the findings with pre-operative F:T PSA ratios.

Results: All of the patients 35 undergoing surgery had clinically localized prostate cancer T2c or less (confirmed with MRI in those with Gleason scores of 3+4 or higher in accordance to an agreed local protocol). 45% (16/35) of patients had F:T PSA ratios of < 10%. Of these 37% (6/16) had extra-capsular extension on pathological examination with 67% (4/6) showing only moderate Gleason scores (3+3) on pre-operative TRUS biopsy (and as such had not undergone further pre-operative imaging). Only one patient (5%) with a moderate Gleason score (3+3) who had a F:T PSA ratio >10% had extra-capsular extension on final pathology.

Conclusion: Patients with moderate Gleason scores < 7 with (<10%) F:T PSA ratios are at a high risk for extra-capsular extension despite otherwise good prognostic markers. F:T PSA ratio predicts more advanced disease and we believe that these patients would benefit from additional pre-operative imaging.

Presented at the: 21^st Saudi Urological Conference North West Armed Forces Hospital - Tabuk 14-16 April 2009

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Characterizing the clinical importance of the index versus the non-index lesion in men with prostate cancer

A. Abdul-Rahman, H. U. Ahmed, A. Freeman, M. Emberton

Department of Urology, Division of Surgery and Interventional Sciences, University College London, London, UK

Objective: The current therapeutic choice for men with localized prostate cancer lies between the two extremes of active surveillance and whole gland radical therapy. Focal therapy represents a novel but currently controversial approach that may be suitable for unilateral or unifocal disease. We assessed the feasibility of focal therapy for localized prostate cancer by examining radical prostatectomy step sections.

Materials and Methods: We reviewed the pathological specimens of 100 consecutive patients acquired over a 24 month period within a single institution. The number of cancer foci (index and non-index lesions), location, volume and Gleason Score (GS) of each lesion was recorded, as well as the presence or absence of any extra-capsular extension.

Results: In all, 335 tumour foci were identified from the 100 specimens; resulting in a mean of 3.4 (range 1 to 8) per prostate. 15% of prostates contained a solitary tumour. These were associated with a mean volume of 1.76 ml (0.2-30.6 mls). Overall, the mean volume of the index tumour was 1.42 mls (range 0.1-30.6 mls), representing 81% (21-100%) of the total tumour volume. The mean volume of the largest non-index tumour was 0.2 mls (range 0.05-1.25 mls). Only fifteen men had a non-index tumour of >0.5 mls, five men had non-index total GS ≥ 7, and five specimens revealed significant non-index tumour with GS ≥ 7 and volume > 0.5 ml. Thirty three foci were extended into the capsule of the prostate. In nearly all of occasions (87%), this was accounted for by the index lesion.

Conclusion: The index lesion in this non-screened and treated population accounted for most of the cancer volume and was attributed with most of the factors that confer risk of progression, according to standard models. Non-index lesions were attributed more than one risk factor in only 5% of men. This rate of clinical significance is likely to be lower in a screened population than those described in this summary. Further work is required in characterizing the aggressiveness of the non-dominant lesions in men with prostate cancer using molecular and genetic markers in addition to the phenotypic ones described above.

Presented at the: 21^st Saudi Urological Conference North West Armed Forces Hospital - Tabuk 14-16 April 2009

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

PSA pattern in the Saudi population

A. Nassir, H. Farsi

Department of Urology, Um Al-Qura University, Makkah and KAUH, Jeddah, Saudi Arabia

Objective: Little is known about prostate cancer in Saudi Arabia. Our aim is to identify the pattern of PSA values in our population.

Materials and Methods: Between October 2002 and November 2007, all PSA values ordered at KFSH&RC in Jeddah were studied. The patient's age, his total PSA, free to total ratio, PSA velocity and any other related data were collected.

Results: The overall average age was 63.8 (+/- 11.8 SD). A total of 4210 specimen of PSA were analyzed for 2181 patients. At their initial presentation; 85%, 8.20% and 6.10% of patients had a PSA of less than 4, 4-10 and > 10 ng/ml, respectively. Free to total PSA ratio for PSA of 4-10 was found to be < 25% and < 18% in 76.8% and 56.2% respectively. PSA velocity was studied in 2803 PSA samples for 801 patients, with an average of 3.5 samples for each patient. Among the 629 patients with PSA < 4, 8.7% progressed. More significantly were the 43 patients with PSA between 4-10: 47.7% progressed. The sum of significant values of absolute PSA, PSA free to total ratio and PSA velocity puts around 10% of all patients undergoing PSA testing as candidates for TRUS guided biopsy.

Conclusion: PSA interpretation needs more effort and research to understand the pathophysiology of prostate cancer in Saudi population.

Presented at the: 21^st Saudi Urological Conference North West Armed Forces Hospital - Tabuk 14-16 April 2009

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

The clinico-pathological patterns of prostatic diseases and prostatic cancer in Saudi patients

H. Mosli, T. Abdel-Meguid, J. Al-Maghrabi, W. Kamal, H. Saadah, H. Farsi

Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Objective: To determine the clinico-pathological patterns of prostatic diseases in Saudi patients, with special emphasis on prostate cancer.

Materials and Methods: The hospitals of King Abdulaziz University Medical City and King Faisal Specialist Hospital are tertiary care teaching hospitals located in Jeddah, Saudi Arabia. The records of patients who underwent histopathological examinations of their prostatic specimens in both hospitals between June 2003 and June 2008 were reviewed retrospectively. The age, indications for biopsy, histological diagnosis, Gleason grading of cancer patients, were studied. The literature was searched for comparative information.

Results: The study included 330 patients with age distribution from 37 to 100 years (median of 68). Specimens included 233 TRUS biopsies, 85 TURPs, 8 simple prostatectomies, 3 radical prostatectomies and 1 radical cystoprostatectomy. Indications for TRUS guided biopsy in prostate cancer patients were elevated PSA, abnormal DRE or both in 85%, 5.5% and 9.3, respectively. PSA values < 4 ng/ml were found in 13.6% of prostate cancer patients. Among others, adenocarcinoma BPH alone, BPH with inflammation and inflammation alone were found in 28.5%, 43.3%, 20.3% and 4.2%, respectively. In specimens of TURP or simple prostatectomy for apparently benign disease, incidental prostate cancer was detected in 14/93 (15%). Gleason sum of ≥ 6 was found in 92.8% of patients. Cancers were poorly differentiated (35%), moderately differentiated (61.4%) or well differentiated (3.6%).

Conclusion: The incidence of prostate cancer in Saudi Arabia is low compared to the western countries. However, incidental prostate cancer detected in presumed benign disease is rising. Further future studies addressing this issue are needed to confirm the potential rising trend, and its possible etiology. Additionally, cancer usually takes place as high grade disease. Our findings support the recommendations to lower the cutoff value for prostatic biopsy to 2.5 rather than 4 ng/ml.

Presented at the: 21^st Saudi Urological Conference North West Armed Forces Hospital - Tabuk 14-16 April 2009

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Transrectal prostatic biopsy for diagnosis of prostatic cancer: Experience of a single center

A. Al-Enizi, K. Madbouly, A. Al-Bakri, S. Ragheb, K. Alghamdi, A. Al-Jasser

Department of Surgery, Urology Division, Security Forces Hospital, Riyadh, Saudi Arabia

Purpose: To review our experience in transrectal prostatic biopsy for prostate cancer diagnosis determining the main indication for the procedure and estimating the relation of cancer diagnosis to different prostatic and biochemical features.

Materials and Methods: A retrospective chart review was performed of patients underwent transrectal prostatic biopsies at our institution between 2000 and 2008. Patients’ charts were reviewed regarding patients’ age and race, family history, symptomatology, findings of digital rectal examination (DRE), serum PSA level and ratio, prostatic ultrasound findings as well as pre-procedure preparation and postoperative complications.

Results: A total of 132 (124 Saudi, 8 non-Saudi) patients were identified with an age of 45 to 93 (median 67) years. None had a family history of prostate ca. Patients presented with obstructive symptoms (94.7%), irritative symptoms (65.9%) and bone pains (6.8%). PSA was the main indication for biopsy (54.5%), abnormal DRE in 9.1%, both in 28.8% while low PSA ratio with normal total PSA was the indication in 6.1%. All prostatic biopsies except 12 (9.1%) were transrectal ultrasound guided. Prostatic adenocarcinoma was diagnosed in 19 patients (14.4%). Four patients had radical prostatectomy and 15 received hormonal treatment. Positive predictive values of PSA, DRE and combined PSA and DRE were 4.2%, 25% and 28.9% respectively. Postoperative complications included fever in 6 patients, hematuria in 15, rectal pain in 12, rectal bleeding in 1 and urine retention in 4 accounting for a complication rate of 28.8%. Four patients required emergency readmission. Complications were not related to patients’ age, PSA symptomatology, prostatic size, echogenicity or calcifications (p=NS). Also, they were not related to biopsy method, pathology results, number of cores sampled, pre-biopsy enema or the duration of pre- or post-biopsy antibiotic course (p=NS). Diagnosis of prostatic carcinoma was not related to high PSA, PSA ratio, prostatic size or prostatic echogenicity (p=NS) but associated with bone pains (p=0.003).

Conclusions: Transrectal prostatic biopsies are safe and feasible. Complications are mild and can be easily managed. Prostate specific antigen is not prostatic carcinoma specific and it had a low predictive value in our group of patients. Additional measures to increase specificity of PSA testing are still necessary. Epidemiologic studies are strongly warranted to determine the incidence of prostatic ca in Saudi population as well as PSA age reference ranges and best PSA cutoff values.

Presented at the: 21^st Saudi Urological Conference North West Armed Forces Hospital - Tabuk 14-16 April 2009

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Predictive parameters in screening for prostate cancer

Khalid Matar Al Otaibi

Department of Urology, University of Dammam, Dammam, Saudi Arabia

Introduction: To review our method of evaluating patients whom we suspect of having prostate cancer.

Methods: A total of 1155 patients underwent transrectal ultrasound (TRUS) and prostate biopsy to investigate the possibility of prostate cancer. The results of these studies, together with digital rectal examination (DRE) and prostate-specific antigen (PSA) were reviewed.

Results: Of the 1155 patients, 318 (27.5%) were found to have prostate cancer, 51 (4%) were diagnosed with PIN, 276 (24%) had evidence of chronic prostatitis and 510 (44%) were diagnosed with benign prostatic hypertrophy (BPH). Of the 318 patients with prostate cancer, 156 (49%) had normal rectal exam and 87 (27.4%) had normal TRUS. 286 (90%) of these prostate cancer patients had initially presented with a high PSA level.

Summary and Conclusion: Normal findings with transrectal ultrasound (TRUS) and digital rectal examination (DRE) does not exclude prostate cancer. Serum PSA is the most sensitive test in predicting the risk of prostate cancer, therefore TRUS and random prostate biopsies should be performed in a case of high PSA or after an abnormal rectal examination.

Presented at the: 22^nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Impact of positive surgical margins after radical prostatectomy differs by disease risk group

Sultan Saud Alkhateeb, Shabbir Alibhai, Neil Fleshner, Antonio Finelli, Michael Jewett, Alexandre Zlotta, Michael Nesbitt, Gina Lockwood, John Trachtenberg

Department of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada

Introduction: Positive surgical margins (PSM) have a negative impact on disease outcomes following radical prostatectomy (RP), yet their prognostic value may vary depending on specific pathological characteristics. We examined the relationship of PSM to biochemical progression according to several clinicopathological features.

Methods: We analyzed data from 1,268 patients who underwent RP for clinically localized prostate cancer at our center between 1992 and 2008 and did not receive any neoadjuvant or adjuvant treatment. We examined the relation of age, pretreatment prostate specific antigen (PSA), pathological T-stage, RP Gleason score, disease risk group and surgical margin status to biochemical progression-free survival (BPFS).

Results: The overall PSM rate was 20.8% and median follow up was 79 months. The impact of PSM was dependent on risk group; BPFS was 99.6% for the NSM group versus 94.9% for the PSM group in low-risk disease (logrank P=0.53), 93.5% for the NSM group versus 83% for the PSM group in intermediate-risk disease (logrank P<0.001) and 78.5% for the NSM group versus 57.1% for the PSM group in high-risk disease (logrank P=0.003). These differences remained significant in a multivariate Cox regression model adjusting for other clinicopathological features.

Summary and Conclusion: PSM is an independent predictor of biochemical progression in intermediate and high-risk prostate cancer. Patients with low-risk disease have a favorable long-term outcome regardless of margin status and may be candidates for expectant management even with PSM, sparing them the side effects and costs of treatment.

Presented at the: 22^nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Does nerve-sparing radical prostatectomy increase the risk of positive surgical margins and biochemical progression?

Sultan Saud Alkhateeb

Department of Urology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada

Introduction: Since the introduction of nerve-sparing radical prostatectomy (NSRP), there have been concerns about the increased risks of positive surgical margins (PSM) and biochemical progression (BP). We examined the relationship of NSRP to PSM and BP using a large, mature data set.

Methods: Patients who underwent RP for clinically localized prostate cancer at our center between 1997 and 2008 were identified. Patients who received neoadjuvant therapy were excluded. We examined the relation of NSRP to the rate of PSM and BP in univariate and multivariate analyses adjusting for clinical and pathological variables including age, pretreatment prostate-specific antigen (PSA) levels and doubling time, pathological stage and grade.

Results: In total, 856 patients were included, 70.9% underwent NSRP and 29.1% had non-NSRP. PSM rates were 13.5% in the NSRP group compared to 17.7% in non-NSRP (P=0.11). In a multivariate analysis, non-NSRP was performed in patients with higher pathological stage (HR 1.95, 95% CI 1.25–3.04, P=0.003) and higher baseline PSA level (HR 1.04, 95% CI 1.01 -1.08, P=0.005). With a median follow up of 41 months, BP-free survival was 88% for non-NSRP compared to 92% for the NSRP group (log rank P=0.018), this difference was not significant in a multivariate Cox regression analysis (HR 0.54, 95% CI 0.28 – 1.06, P=0.09).

Summary and Conclusion: When used in properly selected patients, NSRP does not seem to increase the risk of PSM and disease progression. The most effective way of resolving this issue is through a randomized clinical trial; however, such a trial is not feasible.

Presented at the: 22^nd Saudi Urological Conference King Faisal Specialist Hospital and Research Centre 15-18 March 2010

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Adenocarcinoma of the prostate: KFSHD experience

Ahmed Harbi, Mohamed A. Gomha, Ibrahim Al-Oraifi, Riyad Al-Mousa, Irfan Khan, Adel Al Dayel

Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Introduction: The incidence and prevalence of prostatic carcinoma in Saudi Arabia is much lower than in Europe and USA. It is our observation that the majority of cases presented to our hospital are in a late disease stage. In this study we review our experience as regards to detection, staging and management of prostatic carcinoma in KFSHD.

Materials and Methods: Between May 2006 and July 2010, 78 patients (pts) were diagnosed with prostate carcinoma in KFSHD. Medical records of these patients were reviewed as regards to clinical presentation, methods of diagnosis, staging, management and outcome.

Results: 78 patients were diagnosed to have prostatic adenocarcinoma with a mean age ± SD of 72 ± 8 y. Patients were diagnosed either by prostatic biopsy (n=75) or incidentally discovered after TURP (n=3). The indications for prostatic biopsy was high PSA or suspicious DRE or both. The median PSA at diagnosis was 52 ng/ml (range: 1.2-16250). Staging was determined based on DRE, biopsy, CT/MRI and bone scan. 2002 TNM staging system was the basis for staging. Organ-confined tumor was defined as tumor that is localized within the prostatic capsule with absence of lymph node or distant metastases. On presentation, lymph node metastases as suggested by the CT/MRI was seen in 41.4%, while bone metastases was seen in 50.8%; lung metastases in 23.5% and liver metastases in 11.8%. 21 pts (26.9%) have organ-confined tumors while 47 pts (50.3%) have non-organ confined tumors. 10 pts did not have adequate staging because CT or bone scan or both were not done (5 had PSA < 20 ng/ml). Among patients with organ-confined tumors 5 underwent (additional one is planned) radical prostatectomy (RP), 6 were treated by radical radiotherapy (one had salvage prostatectomy), 4 were on watchful waiting (patient choice or unfit for surgery) and 5 were treated by hormonal therapy (stage 2C in 4, PSA > 30 ng/ml in 3, age > 70 y in 4). The majority of pts with non-organ confined disease were treated by hormonal therapy; one pt underwent radical prostatectomy and one pt received radical radiotherapy. Patient were followed up with a mean period of 17.3 ± 15 mon. Among pts who underwent RP, 3 have PSA of <0.02 ng/ml, 2 lost to follow up and one has PSA of 0.26 ng/ml with enlarged pelvic lymph node. The patient with salvage prostatectomy progressed 8 mon after surgery with PSA of 1900 ng/ml. Among patients treated by hormonal therapy, 56% become hormone refractory within a follow up period of 17.1 ± 15 mon and 34% are dead.

Conclusions: High percentage of patients with prostatic carcinoma still present with advanced staged in Saudi Arabia. This pattern denies many patients the intent to cure treatment and contribute to their mortality.

Presented at the: 23^rd Saudi Urological Conference King Fahd Specialist Hospital - Dammam 21-24 February 2011

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Validation of Epstein criteria of insignificant prostate cancer in Middle East

Ihab A. Hekal, Nasr A. El-Tabey, Mohamed Adel Nabeeh, Ahmed El-Assmy, Mohamed Abd El-Hameed, Adel Nabeeh, Elhousseiny I. Ibrahiem

Institution Urology and Nephrology Center, Cairo, Egypt

Background: Since the introduction of Contemporary Epstein criteria, it has been studied and validated in many countries and among many nations. However, they were not validated in Middle East patients up till now.

Aim of the Work: To validate the Contemporary Epstein criteria in Middle East patients.

Materials and Methods: During the past 8 years, 70 cases underwent radical prostatectomy for T1c prostate cancer. Contemporary Epstein criteria were applied retrospectively on prostatic biopsies. Among our patients, 35 cases met the criteria for clinically insignificant prostate cancer. Pathological revision of the prostatic biopsies, definitive prostatectomy specimens and re-staging were done by single pathologist. Assessment of recurrence rate was done. Up and down grading of the Gleason scoring was studied.

Results: The preoperative data and biopsy results using the Contemporary Epstein criteria were fulfilled on 35 cases. On definitive pathology, 16 cases (45.7%) had Gleason score 6, while 8.6% of cases are non-organ confined (2 cases and 1 case with extra-capsular and seminal vesicles infiltrations, respectively). Both lobes were involved in 20 cases. Moreover, 40% (14 cases) showed upgrading of the score. Lymphatic permeation was recognized in four cases. Mean follow up time 88.1 months, 8.6% cases developed metastasis.

Conclusion: Whenever Epstein criteria are applied in the Middle East patients, the decision of active surveillance based on clinically insignificant prostate cancer (who met the Epstein criteria) will miss nearly 46% of unfavorable prostate cancer. As well as a risk of later metastasis could be in 8.6% of them.

Presented at the: 23^rd Saudi Urological Conference King Fahd Specialist Hospital - Dammam 21-24 February 2011

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Endorectal magnetic resonance imaging directed prostatic biopsy in patients with elevated prostate specific antigen levels and prior negative biopsy

M. Saleem Wani, Arif Hamid, Farooq Ahmad, Feroz Shaheen, Tariq Gojwari

Sheri-Kashmir Institute of Medical Sciences, Srinagar, India

Introduction: The main stay of prostate cancer detection is by TRUS guided biopsy. But this investigation has certain limitations in detecting suspicious lesions or regions harboring malignancy. The objective of our study was to determine the accuracy of TRUS guided biopsy directed with magnetic resonance spectroscopic imaging in patients with an elevated prostate specific antigen (PSA) level and prior negative biopsy and also to determine the advantages of endorectal coil MRI over TRUS in determining the suspicious lesions in prostate.

Materials and Methods: MR imaging and MR spectroscopy were performed in 95 men with increased PSA and prior negative biopsy. MRI and MR spectroscopy findings were rated for presence or absence of prostate cancer on a 5 point scale (1 = definitely absent, 5 = definitely present) by a single experience observer. Metabolic criteria (abnormal voxels) were overlaid on the corresponding transrectal ultrasound images and used to perform voxel guided biopsy of prostate. Subsequent sextant biopsy was used as the standard of reference.

Results: 75 (85.2%) of 88 showed metabolic abnormalities that were suspicious for cancer (voxels score > 4). 13 (14.75%) patients with negative MRI and MR spectroscopy results also had negative biopsy findings. Cancer was detected in 66 (85%) of 75 with positive MR spectroscopic imaging findings (Voxel with score > 4).

Conclusion: The addition of MR imaging and metabolic data from MR spectroscopic imaging improves the ability to determine the prostatic cancer in men with rising PSA levels and negative findings at prior biopsy.

Presented at the: 23^rd Saudi Urological Conference King Fahd Specialist Hospital - Dammam 21-24 February 2011

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Incidental prostatic carcinoma in prostatic chips removed for benign prostatic hyperplasia in a cohort of Saudi population: Experience of a single center

Fahad Al Mashat, Khaled Madbouly, Mohammed Al Askari, Samir Ragheb, Khaled Alghamdi, Abdullah Al-Jasser

Department of Surgery, Urology Division, Security Forces Hospital, Riyadh, Saudi Arabia

Introduction Background: Carcinoma of the prostate is the most common cancer in males in the United States. It is rare in Asians and is thought to of low incidence in Saudi population. Prostatic carcinoma may be discovered incidentally, either at postmortem examination or in a surgical specimen removed for other lesions as nodular hyperplasia. The rate of incidental prostatic carcinoma in prostatic chips removed because of Benign Prostatic Hyperplasia (BPH) in the Western World is between 10 and 22%.

Purpose: To report the incidence of incidental prostatic adenocarcinoma in a cohort of Saudi males subjected to TURP for Benign Prostatic Hyperplasia.

Materials and Methods: Charts of men subjected to TURP in the last 8-year period were retrospectively reviewed. History of obstructive and/or irritative symptoms, hematuria, indwelling urethral catheter and history of previous TURP as well as associated morbidity were reported. Findings of digital rectal examination were recorded. Results of preoperative serum creatinine and electrolytes, PSA and hemoglobin, preoperative uroflowmetry as well as preoperative renal and pelvic ultrasound were collected. Details of the operative procedure with special emphasis on resection time, weight of resected prostatic tissue, associated urethral stricture or vesical stone were retrieved. Reported histopathology was obtained.

Results: A preliminary report of 100 patients is presented. They had a mean age of 72.8 + 10.6 years. Associated diabetes mellitus, bronchial asthma and/or cardiac comorbidities were encountered in 79% of the patients and a history of one or more anticoagulants was encountered in 11%. Obstructive symptoms were the main presentation, 9% had a history of hematuria and 55% presented with indwelling urethral catheter. The majority of the prostates (60%) were moderately enlarged by DRE and were clinically of benign consistency except 2. The mean preoperative s.cr, PSA and Hemoglobin were 102.6 + 54.2 umol/l, 6.6 + 7.4 Ugm/l and 13.7 + 1.7 gm% respectively. Evidence of infection in preoperative urine culture was detected in 21.2% of patients. A mean of 24.97 + 12.2 gms of prostatic tissue was resected. Associated cystolitholapaxy of concomitant bladder stone(s) was performed in 12% of the patients. The histology of prostatic adenocarcinoma was not encountered in any of the removed chips.

Conclusion: Incidental prostatic adenocarcinoma in prostatic chips removed for BPH in Saudi population is very low compared to the western world. This may reflect the notion of low incidence of prostatic carcinoma in Saudi population. Further studies with larger patient numbers are still warranted.

Presented at the: 23^rd Saudi Urological Conference King Fahd Specialist Hospital - Dammam 21-24 February 2011

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Long-term outcome of randomized trial between cryoablation and external beam therapy for locally advanced prostate cancer

Ali Al-Zahrani, Ana M. Autran, Andrew Williams, Glenn Bauman, Joseph Chin

Department of Urology, London Health Science Center, University of Western Ontario, Ontario, Canada

Introduction: Our primary objective is to assess and compare the survival outcomes between cryoablation (CRYD) and External Beam Radiation Therapy (EBRT) in locally advanced prostate cancer (T2c-T3b).

Materials and Methods: Patient with cT2c-cT3b prostate cancer (CaP) (PSA < 25ng/ml, negative metastatic evaluation on CT and bone scan), initially recruited for the trial from 1999 to 2002, were randomized to either primary CRYO (Cryocare System, Endocare Inc., Irvine, CA, USA) or EBRT (66 Gy in 33 fractions, administered at 2 Gy per day, 5 days a week for 6.5 weeks, directed at the prostate, seminal vesicles, and peri-prostatic region). All patients received neoadjuvant hormonal therapy (HT) for 3 months prior and continued for 3 months after the procedures. Patients underwent regular trans-rectal ultrasound and biopsy up to 24 months of follow up (at 3, 6, 12, 18, 24 months for CRYO and at 18, 24 months for EBRT) and as clinically indicated thereafter. Biochemical failure was based on the Phoenix criteria (PSA nadir + 2ng/dl). Biochemical disease-free survival (bDFS), disease-specific survival (DSS) and overall survival (OS) were analyzed with Kaplan-Meier curve.

Results: Median follow up was 105.2 (± 35.8) months. Accrual of data was limited due to newer data favoring longer neoadjuvant HT and higher EBRT dose for patients for locally advances CaP. Sixty two patients completed the trial. Preoperative demographic and clinicopathological characteristics of both groups were comparable. Prostate volume before therapy was smaller in the CRYO group (31.3 ml vs 40.9 ml) (p=0.01). There was greater reduction in prostate volume in the CRYO group after intervention (-54% vs 34%) (p=0.01). DSS and OS were comparable between both groups. The 8-year bDFS significantly lower in the CRYO group (17.4% vs 59.1%) (p=0.01), however median time to bDFS was not significantly different.

Conclusion: The randomized trial showed that CRYO was inferior to EBRT in attaining bDFS close to 9 years in patients with locally advanced CaP (cT2c-T3). A recent randomized trial for more localized CaP showed favorable outcome with CRYO. CRYO may be more suited for less bulky CaP or longer neoadjuvant HT is required for optimal bDFS.

Presented at the: 23^rd Saudi Urological Conference King Fahd Specialist Hospital - Dammam 21-24 February 2011

Urol Ann. 2016 Jan;8(Suppl 1):S53–S73.

Impact of positive surgical margins on progression after radical prostatectomy

M. A. Aggamy, T. Solomon¹, C. C. Abbou¹

Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia, ¹Department of Urology, Henry Mondor Hospital, Paris, France

Introduction: Post radical prostatectomy positive surgical margins (PSM) have been reported as one of the many risk factors associated with higher incidence of biochemical failure and disease progression. Incidence of PSM varies between different series and ranges between 10% - 60%. Due to incongruity between the presence of PSM and biochemical failure, decision of further management, in particular need for and timing of adjuvant or salvage treatment remain difficult, more so controversial. Several factors such as location (apical vs. others), number of margins (unifocal vs. multifocal) and stage of disease have been studied to risk stratify the recurrence of the disease. Many debatable questions arise, however, whether biochemical failure represents a local or systemic disease in patients with PSM?; What is the incidence of clinic progression?; Do all patients with biochemical failure need secondary treatment? What is impact of treatment on the cancer specific and overall survival? Most of data available comes from screened population in the United States of America.

Objectives (Aim of the Study): Is there as need for secondary treatment in patients after biochemical recurrences with positive surgical margins compared with negative surgical margins?

Materials and Methods: Study population consists of 1275 consecutive patients with a mean age of 63.2 years (2.4) who underwent radical prostatectomy for localised prostate cancer at our institution between January 1988 and January 2005. All patients underwent radical prostatectomy by different approaches. Prostatectomy specimens were analysed using Stanford technique by the same pathologist. Data on demographic details, preoperative PSA level, Gleason score, pathological stage, and follow up was collected prospectively. Patients were followed up postoperatively with PSA determinations every 3 months for the first year, 6 monthly for the second year, and annually thereafter. None of the patients had any adjuvant treatment following radical prostatectomy. Biochemical recurrence was compared between patients with positive surgical margins (110/375, 29.5%) and negative surgical margins (90/903, 12.4%). Patients with progressive rise in PSA level (two values at least 3 months apart) were considered for additional or secondary treatment. If first line treatment failed, a second line treatment was offered. Biochemical recurrence was defined as a single PSA of at least 0.2 ng/ml. Patients with nodal metastasis were excluded from the study.

Results: Survival analysis using Kaplan-Meir curves shows a higher rate of biochemical failure in patients with positive surgical margins compared to patients with negative surgical margins in pT2 disease and was statistically significant (p Value <0.0001). Out of 372 (372/1275); 29.9%) patients with positive surgical margins, 110 (29.5%) had biochemical recurrence. Out of those, ninety six (96/110); 87%) underwent additional salvage treatment (Radiotherapy in 71; hormonal therapy in 23 and chemotherapy in 2), mostly within first 2 years of radical prostatectomy.

Conclusions: Obviously some prostate cancers (specially organ-confined tumors) have an excellent prognosis in spite of the positive surgical margins status. On the other side there are advanced cancers that have a bad prognosis regardless of margin status, the margin status independently influences the prognosis only in some patients. It clearly reveals that a positive surgical margin does not necessarily mean that cancer is left behind impact of. In another word, it is not the margin status alone that drives prognosis.

Presented at the: 23^rd Saudi Urological Conference King Fahd Specialist Hospital - Dammam 21-24 February 2011

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