Transition Zone Volume Research Articles

Effect of total prostate volume and transitional zone volume on the curative effect of transurethral resection of prostate in benign prostatic hyperplasia

Objective: To compare the clinical effect of different total prostate volume (TPV) and different transitional zone volume (TZV) on benign prostatic hyperplasia (BPH) treated with transurethral resection of prostate(TURP). Methods: Clinical data of 210 patients with BPH admitted to Guizhou provincial people's hospital from June 2016 to August 2018 were retrospectively collected and analyzed. All patients underwent transrectal ultrasonography, and they were divided into three groups according to TPV: 70 patients in group A:TPV<40mL, 98 patients in group B: 40 ml≤TPV<80 ml, and 42 patients in group C:TPV≥80 ml. Meanwhile, three groups were divided according to TZV: 88 patients in group a: TZV<20ml, 67 patients in group b: 20 ml≤TZV<40 ml, and 55 patients in group c:TZV≥40 ml. All of the patients with TURP were followed up for 6 months after surgery, and the data of international prostate symptom score (IPSS), storage symptoms IPSS (IPSS-S), voiding symptoms IPSS (IPSS-V), Quality of Life (QoL) index, and maximum urinary flow rate (Qmax) were collected before and after surgery. Finally, the effect of TPV and TZV on TURP was analyzed respectively by analysis of variance. Results: There were no statistically significant differences in preoperative IPSS, IPSS-V, IPSS-S, QoL and Qmax among the three groups of patients grouped by TPV (P>0.05), but the age of patients in group C(73.5±6.5) was significantly higher than that in group A (69.3±7.6) and group B (70.9±7.3) (P=0.015). Postoperative IPSS, IPSS-V, IPSS-S, QoL and Qmax of patients in groups A, B and C also showed no significant difference (P>0.05). There were no statistically significant differences in preoperative IPSS, IPSS-V, IPSS-S, QoL, and Qmax among the three groups of patients grouped according to TZV (P>0.05), while the age of patients in group a (69.2±7.6) was significantly lower than that of patients in group b (72.1±7.2) and group c (72.5±6.7) (P=0.017). There were statistically significant differences in IPSS (P=0.010), IPSS-V (P=0.037), IPSS-S (P=0.022), QoL (P=0.038) and Qmax (P=0.037) among the groups a, b, and c after surgery. Moreover, IPSS, IPSS-V, IPSS-S and QoL were negatively correlated with TZV, while Qmax was positively correlated with TZV. Postoperative IPSS, IPSS-V, IPSS-S, QoL and Qmax were significantly different from those before surgery in groups A, B, C and groups a, b, c (P<0.001). Conclusion: TPV and TZV may not be significantly correlated with BPH symptoms, but may be correlated with age. TURP is an effective treatment for patients with different TPV and TZV. There is no significant statistical difference in the surgical efficacy among patients with different TPV, but patients with larger TZV tended to have better outcome. TZV may be better than TPV in predicting the postoperative efficacy.

The effect of pharmacotherapy on prostate volume, prostate perfusion and prostate-specific antigen (prostate morphometric parameters) in patients with lower urinary tract symptoms and benign prostatic obstruction. A systematic review and meta-analysis.

IntroductionThe clinical effect of pharmacotherapy on prostate morphometric parameters is largely unknown. The sole exception is 5α-reductase inhibitors (5-ARI) that reduce prostate volume and prostate-specific antigen (PSA). This review assesses the effect of pharmacotherapy on prostate parameters effect on prostate parameters, namely total prostate volume (TPV), transitional zone volume (TZV), PSA and prostate perfusion.Material and methodsWe conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) reporting on morphometric parameters’ changes after pharmacotherapy, as primary or secondary outcomes. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RCTs’ quality was assessed by the Cochrane tool and the criteria of the Agency for Healthcare Research and Quality. The effect magnitude was expressed as standard mean difference (SMD). The study protocol was published on PROSPERO (CRD42020170172).ResultsSixty-seven RCTs were included in the review and 18 in the meta-analysis. The changes after alpha-blockers are comparable to placebo. Long-term studies reporting significant changes from baseline, result from physiologic growth. Finasteride and dutasteride demonstrated large effect sizes in TPV reduction ([SMD]: -1.15 (95% CI: -1.26 to -1.04, p <0.001, and [SMD]:-0.66 (95% CI: -0.83 to -0.49, p <0.001, respectively), and similar PSA reductions. Dutasteride’s effect appears earlier (1st vs 3rd month), the changes reach a maximum at month 12 and are sustained thereafter. Phosphodiesterase-5 (PDE-5) inhibitors have no effect on morphometric parameters. Phytotherapy’s effect on TPV is non-significant [SMD]: 0.12 (95% CI: -0.03 to 0.27, p = 0.13). Atorvastatin reduces TPV as compared to placebo (-11.7% vs +2.5%, p <0.01). Co-administration of testosterone with dutasteride spares the prostate from the androgenic stimulation as both TPV and PSA are reduced significantly.ConclusionsThe 5-ARIs show large effect size in reducing TPV and PSA. Tamsulosin improves perfusion but no other effect is evident. PDE-5 inhibitors and phytotherapy do not affect morphometric parameters. Atorvastatin reduces TPV and PSA as opposed to testosterone supplementation.

IJU this issue

This issue contains 15 Original Articles, three of which are excellent prospective clinical trials, and one Urological Note. Cabozantinib is a multiple receptor tyrosine kinase inhibitor targeting MET (c-MET), VEGFR2, RET, AXL, KIT and TIE-2. In the phase III, randomized, open-label METEOR study, cabozantinib was associated with a significant progression-free survival benefit and a greater objective response rate versus everolimus in patients with metastatic renal cell carcinoma who had progressed after VEGFR-TKI. Tomita et al. (Niigata, Japan) carried out a bridging study to METEOR to evaluate the efficacy and safety of cabozantinib in Japanese patients. This phase II, open-label, single-arm study showed that cabozantinib provided clinical benefits in Japanese patients with renal cell carcinoma, with similar efficacy and safety to the non-Japanese population. Medical lasers are increasingly used to treat benign prostatic hyperplasia. Shoji et al. (Isehara, Japan) carried out a randomized prospective study to compare functional outcomes and complications over a period of 12 months in benign prostatic hyperplasia treated with thulium laser enucleation of the prostate or bipolar transurethral resection of the prostate. This study showed that thulium laser enucleation of the prostate is superior to bipolar transurethral resection of the prostate in resected volume, resected rates per prostate volume and transition zone volume, hemostasis, catheterization and hospitalization time, and decrease in prostate-specific antigen. However, excessive laser irradiation time in thulium laser enucleation of the prostate has the possibility to delay improvement of overactive bladder symptoms and decrease sexual function. Loose seeds and stranded seeds are available for low-dose rate brachytherapy. Each method has its own advantages and disadvantages, such as flexibility and fixation. Tanaka et al. (Kashihara, Japan) carried out a randomized controlled trial to compare the post-implant dosimetric parameters between the conventional method (using only the loose seeds) and the hybrid method. This study showed that the hybrid method of low-dose rate brachytherapy can achieve a higher coverage of the periprostatic region compared with the conventional method, while maintaining an acceptable level of urethral and rectal doses. The intravesical recurrence rate after transurethral resection of bladder tumor carried out for non-muscle-invasive bladder cancer (NMIBC) is high, and some risk factors for recurrence have been identified. Sazuka et al. (Chiba, Japan) evaluated the risk of the residual urine volume and preoperative pyuria in intravesical recurrence after transurethral resection of bladder tumor among NMIBC patients. They found that the presence of residual urine and pyuria raised the risk of intravesical recurrence after transurethral resection of bladder tumor for NMIBC. Furthermore, especially in men, the recurrence-free survival was significantly higher in patients without than with residual urine by propensity score matching analysis. Iwasawa et al. (Tokyo, Japan) investigated the relationship between fluid intake and tumor recurrence in NMIBC patients by using urine-specific gravity as an indicator of daily fluid intake. They found that high urine-specific gravity was associated with tumor recurrence, especially in patients not receiving adjuvant bacillus Calmette–Guérin therapy. This showed that increasing fluid intake might prevent recurrence in relatively low-risk NMIBC patients. Testicular microlithiasis (TM) is a relatively rare condition occurring in the testicular parenchyma that is characterized by multiple bright and small foci without acoustic shadow limited to the testicle on scrotal ultrasonography. TM is a characteristic of testicular dysgenesis syndrome and was shown to be associated with infertility. Hiramatsu et al. (Tokyo, Japan) evaluated the correlation between the degree of severity in TM and several factors. This study showed the prevalence of TM in normal healthy Japanese men who are trying for first-time pregnancy. This also showed that men with TM might have poor semen findings, and that men with severe TM might have even worse semen parameters. None declared.

Prostatic anatomical parameters correlate with clinical characteristics suggestive of benign prostatic hyperplasia.

We conducted the present study to assess the correlation of the prostatic anatomical parameters, especially the ratio of peripheral zone thickness and transitional zone thickness, with clinical and uroflowmetry characteristics suggestive of benign prostate hyperplasia (BPH). A total of 468 consecutive patients with a detailed medical history were identified. All patients were evaluated by scoring subjective symptoms with the International Prostate Symptom Score (IPSS) and quality of life (QoL). The prostatic anatomical parameters were measured using transrectal ultrasonography, and postvoid residual urine and maximum flow rate (Qmax) values were also determined. Pearson's correlation analysis revealed that both total prostate volume (TPV; r = 0.160, P < 0.001) and transitional zone volume (TZV; r = 0.104, P = 0.016) increased with patients' age; however, no correlations were observed of TPV, TZV, transitional zone index (TZI), and transitional zone thickness (TZT) with IPSS or QoL (all P > 0.05). Peripheral to transitional zone index (PTI) was found negatively correlated with total IPSS (r = −0.113, P = 0.024), storage IPSS (r = −0.103, P = 0.041), and voiding IPSS (r = −0.123, P = 0.014). As regards the uroflowmetry characteristics, PTI (r = 0.157, P = 0.007) was indicated to be positively correlated with Qmax and negatively correlated with TZI (r = −0.119, P = 0.042) and TZT (r = −0.118, P = 0.045), but not correlated with TPV, TZV, or peripheral zone thickness (PZT) (all P > 0.05). Postvoid residual urine (PVR) had not correlated with all the prostatic anatomical variables (all P > 0.05). This is the first study that formally proposed the concept of PTI, which is an easy-to-measure prostate anatomical parameter which significantly correlates with total IPSS, storage IPSS, voiding IPSS, and Qmax, suggesting that PTI would be useful in evaluating and managing men with lower urinary tract symptoms (LUTS)/BPH. However, well-designed studies are mandatory to verify the clinical utility of PTI.

Diagnostic performance of transrectal ultrasound for prostate volume estimation in men with benign prostate hyperplasia

Despite transrectal ultrasound (TRUS) being regarded as gold standard for prostate volume estimation, concerns have been raised in the literature concerning its accuracy especially in men with above-average prostate volumes. We aimed to evaluate the performance of TRUS for prostate volume estimation in a cohort of sub-Saharan African men since they are known to have relatively large mean prostate volumes. This was a prospective study of 77 sub-Saharan African men who had open simple prostatectomy for benign prostate hyperplasia (BPH). Pre-operative TRUS determined total prostate volume (TPV) and transition zone volume (TZV). Following surgical enucleation, the adenoma was weighed (EPW) and its volume (EPV) also determined by fluid displacement. TRUS was repeated six weeks post-operatively to calculate the TRUS-estimated specimen volume (TESV). The mean EPV, EPW, TRUS-estimated TZV, TRUS-estimated TPV and TESV were 79.1 ± 62.9 ml, 79.1 ± 62.9 g, 53.3 ± 28.5 ml, 93.1 ± 48.9 ml and 69.9 ± 44.6 ml, respectively. Pearson's correlation showed a perfect relationship between EPW and EPV with no difference in their mean values (r = 1.000; P < .001). Pearson's correlation between TRUS-estimated TPV vs EPV, TRUS-estimated TZV vs EPV, and between TESV vs EPV were 0.932, 0.865 and 0.930, respectively (P = .0000). TRUS significantly under-estimated the TZV and TESV by 25.8 ml and 9.2 ml, respectively; unrelated to the severity of prostate enlargement. TRUS underestimates prostate volume, independent of prostate size. We propose simple formulae that could be used to improve the prostate volume determination from TRUS, especially if magnetic resonance imaging is not readily available or contraindicated.

Clinical predictive factors in prostatic artery embolization for symptomatic benign prostatic hyperplasia: a comprehensive review.

Prostatic artery embolization (PAE) has been established as a routine treatment for symptomatic benign prostatic hyperplasia (BPH) all over the world. With increasing clinical experience in the last decade, investigators have sufficient data to assess predictive factors with the purpose to guide patient selection and counseling for PAE or to individualize therapeutic plans after PAE. This paper is a comprehensive review to introduce the concept of clinical predictors and give a systemic classification of various predictive factors in PAE. The authors review each individual factor and its predictive capability and discuss the possible reasons for the inconsistent or conflicting findings in the literature. Based on current evidence, the baseline prostate volume, in particular the transition zone volume and transition zone index; 24 h post-PAE prostate-specific antigen (PSA) level; and prostate infarction and prostate volume reduction at 1–3 months have potential in prediction of treatment outcomes. Patients with Adenomatous-dominant BPH or with indwelling bladder catheter before PAE may have more benefits from PAE. Baseline intravesical prostatic protrusion (IPP), C-reactive protein (CRP) level at 48 h and early detection of prostate infarct at 1 day and 1 week after PAE need further investigating.

Elevated prostate volume index and prostatic chronic inflammation reduce the number of positive cores at first prostate biopsy set: results in 945 consecutive patients.

ABSTRACTObjective To assess the association between prostate volume index (PVI), and prostatic chronic inflammation (PCI) as predictors of prostate cancer (PCA). PVI is the ratio between the central transition zone volume (CTZV) and the peripheral zone volume (PZV).Materials and methods Parameters evaluated included age, prostate specific antigen (PSA), total prostate volume (TPV), PSA density (PSAD), digital rectal exam (DRE), PVI, PCI and number of positive cores (NPC). All patients underwent baseline 14-core, trans-perineal random biopsies. Associations of parameters with the NPC were investigated by univariate and multivariate linear regression analysis.Results Between September 2010 to September 2017, 945 patients were evaluated. PCA was detected in 477 cases (50.7%), PCI in 205 cases (21.7%). PCA patients, compared to negative cases, were older (68.3 vs. 64.4 years) with smaller TPV (36 vs. 48.3mL) and CTZV (19.2 vs. 25.4), higher PSAD (0.24 vs. 0.15ng/mL/mL), further PVI values were lower (0.9 vs. 1.18) and biopsy cores less frequently involved by PCI (9.4% vs. 34.2%).High PVI and the presence of PCI were independent negative predictors of NPC in model I considering PSA and TVP (PVI, regression coefficient, RC -0,6; p=0.002) and PCI (RC -1,4; p <0.0001); and in model II considering PSAD (PVI:RC -0,7; p <0,0001; and PCI: RC -1,5; p <0.0001).Conclusions High PVI and the presence of PCI lowered the mean rate of NPC and is associated with less aggressive tumor biology expressed by low tumor burden. PVI can give prognostic information before planning baseline random biopsies. Confirmatory studies are required.

Added Value of Biparametric MRI and TRUS-Guided Systematic Biopsies to Clinical Parameters in Predicting Adverse Pathology in Prostate Cancer.

ObjectiveTo develop novel models for predicting extracapsular extension (EPE), seminal vesicle invasion (SVI), or upgrading in prostate cancer (PCa) patients using clinical parameters, biparametric magnetic resonance imaging (bp-MRI), and transrectal ultrasonography (TRUS)-guided systematic biopsies.Patients and MethodsWe retrospectively collected data from PCa patients who underwent standard (12-core) systematic biopsy and radical prostatectomy. To develop predictive models, the following variables were included in multivariable logistic regression analyses: total prostate-specific antigen (TPSA), central transition zone volume (CTZV), prostate-specific antigen (PSAD), maximum diameter of the index lesion at bp-MRI, EPE at bp-MRI, SVI at bp-MRI, biopsy Gleason grade group, and number of positive biopsy cores. Three risk calculators were built based on the coefficients of the logit function. The area under the curve (AUC) was applied to determine the models with the highest discrimination. Decision curve analyses (DCAs) were performed to evaluate the net benefit of each risk calculator.ResultsA total of 222 patients were included in this study. Overall, 83 (37.4%), 75 (33.8%), and 107 (48.2%) patients had EPE, SVI, and upgrading at final pathology, respectively. The addition of bp-MRI data improved the discrimination of models for predicting SVI (0.807 vs 0.816) and upgrading (0.548 vs 0.625) but not EPE (0.766 vs 0.763). Similarly, models including clinical parameters, bp-MRI data, and information on systematic biopsies achieved the highest AUC in the prediction of EPE (0.842), SVI (0.913), and upgrading (0.794), and the three corresponding risk calculators yielded the highest net benefit.ConclusionWe developed three easy-to-use risk calculators for the prediction of adverse pathological features based on patient clinical parameters, bp-MRI data, and information on systematic biopsies. This may be greatly beneficial to urologists in the decision-making process for PCa patients.

Prostatic peripheral zone thickness: what is normal on magnetic resonance imaging?

To report the precision of a technique of measuring the PZ thickness on T2-weighted MRI and report normal parameters in patients with normal-sized prostates. We also wanted to establish the mean and second standard deviations (2SD) above and below the mean as criteria for abnormally narrow or expanded PZ thickness. Of the initial 1566 consecutive cohort referred for evaluation for carcinoma based on elevated PSA (prostate specific antibody) or DRE (digital rectal examination), 132 separate subjects with normal-sized prostates were selected for this study. Mean age was 58.2years (15-82). Median serum PSA was 6.2ng/mL (range 0.3-145). Most were asymptomatic for lower urinary tract symptoms (LUTS). Inclusion criteria in this study required technically adequate T2-weighted MRI and total prostatic volume (TPV) ≤ 25cc. Exclusion criteria included post-prostatic surgical and radiation patients, patients having had medical management or minimally invasive therapy for BPH, those being treated for prostatitis. Patients with suspected tumor expanding or obscuring measurement boundaries were also not considered. Transition zone (TZ) and peripheral zone (PZ) volumes were determined using the prolate ellipsoid model. Posterolateral measurement of the PZ was obtained at the axial level of maximal transverse diameter of the prostate on a line drawn from the outer boundary of the TZ to the inner boundary of the external prostatic capsule (EPC). The data were normally distributed. Therefore, it was analyzed using the 2-sided student t-test and Pearson product correlation statistic. Mean pooled (composite) measurement for the posterolateral PZ (PLPZ) was 10mm (CI 9.5-10.5mm) with SD of 2.87mm. Means were statistically the same for the 2 observers (p = 0.75). Pearson correlation between the two observers was 0.63. In a prostate ≤ 25cc volume , the posterolateral PZ should be no thicker than 15.8mm and averages 10.0mm when measured in the maximal axial plane on MRI. These norms were independent of age or use of endorectal coil. The technique measurement demonstrated clinically useful precision.

IMPACT OF MEMBRANOUS URETHRAL LENGTH IN DE NOVO STRESS URINARY INCONTINENCE FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE

(Purpose) Holmium laser enucleation of the prostate (HoLEP) is widely performed in recent years; however, difficulties of surgical techniques and high frequency of postoperative stress urinary incontinence (SUI) remain as significant problems. We determined the predictive factors for de novo SUI after HoLEP. (Patients and methods) A total of 303 patients with benign prostatic hyperplasia who underwent HoLEP were retrospectively evaluated between July 2013 and April 2019. Of these, 109 patients underwent MRI preoperatively. Patients who were unable to answer the questionnaire regarding their SUI because of dementia, those who presented with SUI preoperatively, and those with placed Foley catheter at the time of MRI were excluded. Hence, a total of 83 patients were eligible for the present study. We recorded the MRI findings and clinical variables, including membranous urethral length (MUL), transitional zone (TZ) volume, serum prostate-specific antigen levels, operative time, and presence or absence of SUI. The predictive factors for de novo SUI were determined using multivariable logistic regression analysis. (Results)De novo SUI occurred in 19 (22.9%) patients but disappeared in 16 (84.2%) patients at a mean duration of 14 weeks. The mean MUL was 17.2 mm. Univariate analysis showed that MRI TZ volume >40 mL, MUL ≤17 mm, operative time >100 min, and enucleation time >50 min were associated with de novo SUI. In multivariable logistic regression analysis, MUL ≤17 mm (odds ratio [OR], 23.81; 95% confidence interval [CI], 4.34-447.19; P < 0.0001) and operative time >100 min (OR, 3.91; 95% CI, 1.20-14.01; P = 0.023) were significantly associated with de novo SUI. (Conclusions) Although de novo SUI occurred occasionally after HoLEP, most of them improved in about 3 months. The MRI measurement of MUL was shown to be a practical tool for predicting de novo SUI after HoLEP.

USE OF PROSTATE AND BLADDER SONOMORPHOLOGY FOR DIAGNOSIS OF BLADDER OUTLET OBSTRUCTION IN PATIENTS WITH SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA

Background: Benign prostatic hyperplasia (BPH) is a common urological problem more frequently seen in elderly people causing lower urinary tract symptoms (LUTS). About 28% of patients with BPH have moderate or severe LUTS and a considerable portion of these patients require LUTS treatment, pressure flow studies PFS is the gold standard for diagnosing obstruction, however the test is invasive, unpleasant costly, time consuming and technically difficult with limited availability to the patient. Objective: To evaluate the accuracy of the bladder and prostate sonomorphologic parameters for the diagnosis of bladder outlet obstruction (BOO) in patients with lower urinary tract symptoms (LUTS) with benign prostatic hyperplasia (BPH). Patients and Methods: A prospective clinical trial was carried out during the period from January 2017 to January 2019 at the Urology Departments; Al-Hussein and Sayed Galal, Al-Azhar University Hospitals, and Police Authority Hospital, Cairo, Egypt to 512 patients seeking treatment for LUTS/BPH underwent a series of measurements, including medical history with LUTS assessment using the International Prostate Symptom Score (IPSS), physical examination with digitorectal and focal neurological examinations, routine urinalysis, and serum creatinine and prostate-specific antigen (PSA) measurements. Results: During the study period, 209 patients completed the follow up protocol and included in the study, the mean age of the study population was 64.51 years, the mean total IPSS score was 19.18, the mean duration of symptoms was 6.4 mo., the mean total prostate volume, transitional zone volume, and transitional zone index were 42.5 g, 25.7 g, and 0.6 respectively. The mean bladder parameters studied intravesical prostatic protrusion, bladder wall thickness was 11.3 mm, 4.85 mm, 30.1 g respectively, the mean prostate parameters studied prostate urethral length, prostate urethral angel were 41.8 mm and 34.3˚. Out of 209 patients studied 113 (54.1%) patients were obstructed (BOO group) and 96 (45.9%) were not (non- BOO group). All parameters were comparable between the two groups. Conclusions: Some sonomorphologic parameters of bladder and prostate (IPP, PUA, BWT and Qmax) are useful alternative to PFS for diagnosis of symptomatic BOO/BPH.

Prostatic chronic inflammation and prostate cancer risk at baseline random biopsy: Analysis of predictors

ABSTRACT Objective To evaluate predictors of prostatic chronic inflammation (PCI) and prostate cancer (PCa) in patients undergoing transperineal baseline random prostatic needle biopsies (BNB). Patient and methods According to BNB outcomes, patients were divided into four groups: cases without PCI or PCa (Control group), cases with PCI only (PCI group), cases with PCa and PCI (PCa+PCI group) and cases with PCa only (PCa group). A multinomial logistic regression model was used to evaluate the association of clinical factors with BNB outcomes. Additionally, clinical factors associated with the risk of PCa in the overall population were investigated using a multivariable logistic regression model (univariate and multivariate analysis). Results Overall, 945 patients were evaluated and grouped as follows: Control group, 308 patients (32.6%); PCI group, 160 (16.9%); PCa+PCI group, 45 (4.8%); and PCa group, 432 (45.7%). Amongst these, PCa was independently predicted by age (odds ratio [OR] 1.081), prostate specific-antigen level (PSA; OR 1.159), transition zone volume (TZV; OR 0.916), and abnormal digital rectal examination (DRE; OR 1.962). PCa and PCI (4.8%) were independently predicted by age (OR 1.081), PSA level (OR 1.122) and TZV (OR 0.954). In the group without PCa, the PSA level was the only factor associated with the risk of PCI when compared to the control group (OR 1.051, P = 0.042). Among patients with PCa, independent factors associated with the risk of only PCa compared to cases with PCA+PCI were TZV (OR 0.972) and number of positive cores (OR 1.149). In the overall population, PCI was the strongest predictor of a decreased risk of PCa (multivariate model, OR 0.212; P < 0.001) Conclusions At BNB, PCI was associated with both a decreased risk of PCa and less aggressive tumour biology amongst patients with PCa. The presence of PCI on biopsy cores should be reported because of its implications in clinical practice. Abbreviations BGG: biopsy Gleason Group; BPC: biopsy positive (cancer) cores; BMI: body mass index; FGF-2: fibroblast growth factor 2; IL: interleukin; ISUP: International Society of Urologic Pathology; NIH: National Institutes of Health; OR: odds ratio; PCa: prostate cancer; PCI: prostatic chronic inflammation; TGF: transforming growth factor; TPV: total prostate volume; TZV: transition zone volume

MRI phenotype of the prostate: Transition zone radiomics analysis improves explanation of prostate-specific antigen (PSA) serum level compared to volume measurement alone

PurposeTo determine the value of a radiomics MRI phenotype of the transition zone to explain PSA level in patients with low suspicion for clinically significant cancer to confirm hyperplastic changes. Materials and methodsT2 weighted images from 36 consecutive PI-RADS 2 and 3 cases with volume adapted systematic transperineal biopsy as reference standard (all biopsies negative, 34.8 biopsy cores per patient in average, mean PSA level 10.77 ng/mL) are manually segmented to define transition zone (TZ) volume. 54 radiomic features (RF) are derived for each TZ. RF are tested for significant correlation with PSA level, Bonferroni correction is applied. We build regression models to explain PSA level with a) TZ volume b) RF c) TZ volume+RF. We apply all models to a control group with clinically significant transition zone cancer. ResultsTZ volume is moderately correlated with PSA level (r = 0.44). 5/54 RF are significantly correlated with PSA level (r: 0.53−0.69, p < 0.05). Inclusion of each of these five features into the regression model significantly improves the explanatory value for PSA level (p < 0.05). Furthermore, RF alone better explain PSA level compared to TZ volume alone (p < 0.01). A systematic and significant trend for positive residuals is observed when regression models are applied to the malignant control group. ConclusionA radiomics analysis of the transition zone has the potential to improve explanation of corresponding PSA level in patients with low suspicion. This knowledge may reassure radiologists to read prostate MRI cases as unremarkable, despite present hyperplastic changes.

Quantitative Characterization of the Prostatic Urethra Using MRI: Implications for Lower Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia

The aim of this study was to perform a quantitative assessment of the prostate anatomy with a focus on the relation of prostatic urethral anatomic variation to urinary symptoms. This retrospective study involved patients undergoing magnetic resonance imaging for prostate cancer who were also assessed for lower urinary tract symptoms. Volumetric segmentations were utilized to derive the in vivo prostatic urethral length and urethral trajectory in coronal and sagittal planes using a piece-wise cubic spline function to derive the angle of the urethra within the prostate. Association of anatomical factors with urinary symptoms was evaluated using ordinal univariable and multivariable logistic regression with IPSS score cutoffs of ≤7, 8-19, and >20 to define mild, moderate, and severe symptoms, respectively. A total of 423 patients were included. On univariable analysis, whole prostate volume, transition zone volume, prostatic urethral length, urethral angle, and retrourethral volume were all significantly associated with worse urinary symptoms. On multivariable analysis prostatic urethral length was associated with urinary symptoms with a normalized odds ratio of 1.5 (95% confidence interval 1.0-2.2, p = 0.04). In a subset analysis of patients on alpha blockers, maximal urethral angle, transition zone volume as well as urethral length were all associated with worse urinary symptoms. Multiple parameters were associated with worse urinary symptoms on univariable analysis, but only prostatic urethral length was associated with worse urinary symptoms on multivariable analysis. This study demonstrates the ability of quantitative assessment of prostatic urethral anatomy to predict lower urinary tract symptoms.

Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article.

Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.

Association Between Prostate Zonal Volume and Erectile Dysfunction in Patients With Benign Prostatic Hyperplasia.

IntroductionThe impact of prostate zonal volume on erectile function and penile Doppler parameters is not yet settled.AimTo assess the association between prostate zonal volume and erectile dysfunction in patients with benign prostatic hyperplasia.MethodsThis cross-sectional analytical study included 70 men (aged ≥ 40 years). Of them, 60 patients were assigned to 3 study groups (n = 20/each): group (A) patients who had lower urinary tract symptoms (LUTSs) and erectile dysfunction (ED), group (B) patients who had LUTSs with no ED, group (C) patients who had ED with no LUTS, and other 10 age-matched patients who had no LUTS or ED acted as a control group (D). All patients were subjected to detailed medical and sexual history. International prostate symptom score (IPSS) was used to assess LUTSs, and international index of erectile function (IIEF) was used to assess ED.Main Outcome MeasureTransrectal ultrasound and penile Doppler ultrasound were used to assess zonal anatomy of the prostate and the vascular pattern of erection.ResultsThere was a significant difference in IPSS between group A (26) and B (19) (P < .05). Each of groups A and C had significant lower peak systolic velocity (PSV) than each of groups B and D (P < .001/each). There was a significant positive correlation between transitional zone index (TZI) and IPSS (r = 0.71, P < .01), and significant negative correlation between TZI and both of IIEF (r = -0.48, P < .05) and PSV (r = -0.606, P < .05).ConclusionThis study clearly demonstrated that there were significant correlations between increased transitional zone volume, TZI, and decreased both of IIEF score and PSV.Qalawena MM, Al-Shatouri MA, Motawaa MA, et al. Association Between Prostate Zonal Volume and Erectile Dysfunction in Patients With Benign Prostatic Hyperplasia. Sex Med 2020;8:205–213.

Effect of transition zone index on the outcome after transurethral resection of prostate

Objective: To investgate the effect of properative transitional zone index (TZI) on the outcome of transurethral resection of prostate (TURP). Methods: A retrospective analysis was performed on 206 patients with TURP who were admitted to our hospital from January 2016 to September 2018. All patients underwent transrectal ultrasound (TRUS) to determine the total prostate volume (TPV) and the transition zone volume (TZV). Patients were divided into two groups according to TZI (TZV/TPV) (group A: TZI<0.5, group B: TZI≥0.5). We collected data 6-months after surgery including international prostate symptom score (IPSS), quality of life score (QOL), maximum flow rate (Qmax), and postvoiding residue (PVR) to compare the difference of the postoperative outcome of two groups, while the IPSS was subdivided into voiding (IPSS-v) and storage(IPSS-s) symptoms, and the changes of IPSS, IPSS-v, IPSS-s, QOL, Qmax and PVR before and after surgery were analyzed. The treatment efficacy was determined as the changes of IPSS (post/preoperative IPSS: %IPSS), QOL (preoperative QOL-postoperative QOL: ΔQOL) and Qmax(preoperative Qmax-postoperative Qmax: ΔQmax). Pearson linear correlation analysis was employed to estimate the correlation of TZI and %IPSS, ΔQOL and ΔQmax, respectively. Results: A total of 126 patients were in Group A, and 80 patients were in group B. 1. The preoperative clinical data of the two groups were compared. There were no significant differences regarding age, IPSS, IPSS-v, IPSS-s, QOL, Qmax, and PVR between two groups (all P>0.05). However, the TPV of patients in group B (74.57±29.25) ml was significantly larger than that in group A (46.25±24.56) ml, P<0.001. While the postoperative follow-up outcomes of the two groups were compared, we found that IPSS-s (P=0.079), QOL (P=0.710), and PVR (P=0.651) were not statistically different between the two groups, but the postoperative IPSS, IPSS-v, and Qmax (8.50±5.75 vs 6.38±4.36, 4.03±3.75 vs 2.63±2.5, and (16.54±4.43) ml/s vs (18.94±4.84) ml/s, all P<0.05) were significantly different between the two groups. 2. Postoperative IPSS, IPSS-v, IPSS-s, QOL, Qmax and PVR were significantly different from those before surgery in two groups, respectively. 3. Pearson linear correlation analysis showed a significant positive correlation between TZI and ΔQmax (r=0.32, P<0.01), a weaker negative correlation between TZI and %IPSS (r=-0.22, P<0.01), and no correlation between TZI and ΔQOL (r=0.08, P=0.238). Conclusion: There may be a correlation between the outcome of TURP and TZI, and the outcome of TURP may be better in patients with TZI ≥ 0.5.

Higher expression of phosphodiesterase type 5 in the anterior fibromuscular stroma of the human prostate.

To examine phosphodiesterase type 5 (PDE5) expression in the anterior fibromuscular stroma (AFMS) of the prostate. Although PDE5 expression was identified in the human prostate, differences in PDE5 expression in intra-prostatic regions are unknown. The AFMS in the prostate has peculiar innervations that could contribute to voiding function. Here, we examined regional differences in PDE5 expression in the prostate with special reference to the AFMS. A total 18 human prostate and bladder specimens were obtained. Tissue specimens were processed by hematoxylin-eosin (H&E) staining and immunohistochemistry for PDE5. Immunoreactivity with PDE5 was evaluated using computer-assisted image analysis in the following regions: the AFMS, bladder neck, stromal hyperplasia in the transition zone, glandular hyperplasia in the transition zone (TZ gland), and the peripheral zone (PZ). The correlation between PDE5 expression in the AFMS and clinical data was analysed. Image analysis revealed that the median ratio of the PDE5-immunoreactive area to smooth muscle area by H&E staining was 74.7% in the AFMS. There was significantly higher PDE5 expression in the AFMS than in the TZ gland (p = 0.034) and PZ (p = 0.002). PDE5 expression in the AFMS was not significantly correlated with age, prostate volume, transition zone volume, or transition zone index. However, older men had a tendency to have higher PDE5 expression in the AFMS. We found higher PDE5 expression in the AFMS compared with other prostatic regions, which suggested that the AFMS is a target region of PDE5 inhibitors in the prostate.

Factors Predisposing to Catheter Reinsertion Following Holmium Laser Enucleation of the Prostate

ObjectiveTo determine if preoperative catheter dependence or specimen weight is associated with failed trial without catheter (TWOC) following holmium laser enucleation of the prostate (HoLEP). Material and MethodsThe study population consisted of 143 consecutive men who underwent HoLEP by a single surgeon over 10 months. Ten were excluded from analysis because they did not have a TWOC on the morning following surgery. Preoperative catheter dependence and specimen weight as well as catheter reinsertions were analyzed. ResultsOf 133 men included in analysis, 23 (17.3%) required catheter reinsertion. Of the 23 requiring catheter reinsertion, 6 were catheter dependent preoperatively and 17 were not. Men who were catheter dependent had a lower overall rate of failed TWOC compared to those who were not catheter dependent (15.0% vs 18.3%, P = .647). Mean specimen weight for men requiring catheter reinsertion was significantly lower than men who passed their TWOC (49.9 gm vs 73.1 gm, P = .013). ConclusionVery few studies exist on factors associated with short-term catheter reinsertion following HoLEP or other prostatic hyperplasia procedures. We hypothesized that preoperative catheter dependence and small specimen weight would predispose to catheter reinsertion. Specimen weight was inversely related to risk of catheter reinsertion after HoLEP and preoperative catheter dependence was not associated with catheter reinsertion. In men with small prostates, consideration should be given to delayed TWOC to allow resolution of capsular edema and accumulation of clot in the prostatic fossa. Transition zone volume below which delayed TWOC should be considered is the subject of future studies.

Impact of Bladder Neck Stiffness on Lower Urinary Tract Symptoms in Patient With Benign Prostatic Hyperplasia

Purpose We evaluated the impact of bladder neck stiffness on lower urinary tract symptoms in the patient with benign prostatic hyperplasia using elastography. Material and Methods A total of 384 patients divided into three different groups according to the bladder neck stiffness based on ultrasound with elastography. Patients age, prostate specific antigen (PSA), International Prostate Symptom Score (IPSS), prostate volumetric parameters, residual urine volume, and laboratory data were collected and compared among the three groups. Results Group 1 (n=121) showed low stiffness in both bladder neck adenoma. Group 2 (n=157) showed low to intermediated stiffness, and group 3 (n=106) showed significantly higher stiffness of bladder neck and adenoma compared to adjacent prostatic tissue. Significant differences among the 3 groups were found in the total prostate volume, transition zone volume, transition zone index, total IPSS, IPSS-voiding, IPSS-storage, residual urine volume, and quality of life. As the stiffness increased, prostate volumetric parameters, and residual urine volume were increased, and lower urinary tract symptoms became exacerbated. No significant difference was found in the patients' age and PSA. Conclusions Bladder neck stiffness affected the lower urinary tract symptoms and prostate volumetric parameters. These findings suggest that the change of bladder neck stiffness can be a novel parameter for the development of lower urinary tract symptoms/benign prostate hyperplasia. Key Words: Prostatic hyperplasia; Lower urinary tract symptoms; Elastography.