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Biomedical subjects

J E Montie

Publications and source records attributed to J E Montie.

At least 19 recordsLinked to original sources
PubMed2001

Age-specific distribution of serum prostate-specific antigen in a community-based study of African-American men.

OBJECTIVES: Previous studies have observed higher age-specific serum prostate-specific antigen (PSA) values in African-American (AA) men without prostate cancer compared to white men, leading some to recommend race-specific PSA reference ranges for the early detection of prostate cancer. The primary objective of the Flint Men's Health Study was to determine age-specific PSA reference values in a community-based sample of AA men, aged 40 to 79 years. METHODS: A probability sample of 943 AA men was selected from households in Genesee County, Michigan. Men without a prior history of prostate cancer/surgery were invited to participate in a prostate cancer screening protocol, consisting of measurement of serum total PSA, free/total PSA ratio, and digital rectal examination. Sextant biopsies were recommended, based on total PSA greater than 4.0 ng/mL and/or an abnormal digital rectal examination. RESULTS: From the sample of 943 men, 732 were eligible, 432 had blood drawn for PSA testing, and 374 completed all phases of the clinical examination. The 95th percentile PSA values were estimated to range from 2.36 ng/mL for men in the fifth decade to 5.59 ng/mL for men in the eighth decade. The 95th percentile values for age-specific PSA were comparable to those observed in a similar study of white men in Olmsted County, Minnesota. The median and 5th percentile values for free/total PSA did not vary significantly across age. CONCLUSIONS: The minor differences in PSA reference ranges between AA and white men may not be of sufficient magnitude to recommend the use of race-specific PSA reference ranges for screening.

Adult↗
PubMed2001

Prospective comparison between hand-assisted laparoscopic and open surgical nephroureterectomy for urothelial cell carcinoma.

OBJECTIVES: To prospectively compare open surgical and the new hand-assisted approach to laparoscopic nephroureterectomy for urothelial cell carcinoma. Previous retrospective studies have suggested that standard laparoscopic nephroureterectomy provides a briefer convalescence than open surgical nephroureterectomy. METHODS: Between March 1997 and September 1999, 16 hand-assisted laparoscopic and 11 open surgical nephroureterectomies were performed, without randomization. Validated questionnaires were prospectively administered preoperatively and 2 and 6 weeks postoperatively. RESULTS: The operative time was longer with the laparoscopic approach (320 versus 199 minutes, P <0.001), but the hospital stay was shorter (3.9 versus 5.2 days, P = 0.03). Patient recovery favored the laparoscopic group with regard to time to drive (17.1 versus 37.7 days), time to normal, nonstrenuous activity (18.2 versus 38.1 days), and the mental component score of the SF-12 survey at 6 weeks (57.1 versus 43.0) (P <0.05 for all). Minor complications occurred in 19% of the laparoscopic and 45% of the open surgical procedures; major complications occurred in 19% of laparoscopic and 27% of open surgical procedures (P >0.1 for both). Cancer control was similar between both groups. The mean operating room cost was 56% more for the laparoscopic group (P <0.001), but the overall hospital cost was only 8% greater (P >0.3). CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy is a safe and effective alternative to an open surgical approach. Indexes of patient recovery suggest that patient convalescence is less than after an open surgical nephroureterectomy. Increased operative costs may be offset by a shorter hospital stay and fewer complications, resulting in similar overall hospital costs.

Aged↗
PubMed2001

Analysis of three-dimensional ultrasound Doppler for the detection of prostate cancer.

OBJECTIVES: To investigate the relative effectiveness of Doppler ultrasound quantitative measures in discriminating prostate cancer from normal prostate tissue. The true locations of prostate cancer within these prostates were determined by histologic examination after radical prostatectomy. METHODS: Three-dimensional Doppler ultrasound data were acquired from 39 men before radical prostatectomy. The removed prostates were sectioned and all cancerous regions in each prostate were identified on whole-mount hematoxylin-eosin-stained slides. The ultrasound and histologic data were then spatially registered. Biopsy results were simulated on a grid of potential sites within each prostate. Along each simulated biopsy site, the amount of cancer was computed from the hematoxylin-eosin-identified cancerous regions and the peak speed-weighted pixel density (SWD) was compared. RESULTS: By selecting the biopsy sites with higher associated SWDs within each sextant, the probability of having at least one positive biopsy within a prostate increased from 75% if the SWD was ignored to 85% if only the top 15% of potential biopsy sites in each sextant were selected. This trend was seen within each sextant individually as well. CONCLUSIONS: Doppler ultrasound provides discriminatory information for prostate cancer using the SWD. Translating this into a practical strategy that might improve the yield of prostate biopsy remains under development. The results of our study indicate that biopsying regions of high Doppler color could potentially increase the cancer yield to a small degree and improve the accuracy of the biopsy results. These results also objectively verify previous visual studies suggesting a modest improvement with the use of color Doppler.

Aged↗
PubMed2001

Predictors of Gleason pattern 4/5 prostate cancer on prostatectomy specimens: can high grade tumor be predicted preoperatively?

PURPOSE: Radical prostatectomy provides excellent cancer control in men with clinically localized prostate carcinoma. However, to our knowledge preoperative parameters for distinguishing indolent from clinically significant cancer are not well characterized. In fact, recent evidence suggests that the percent of Gleason pattern 4/5 carcinoma in the complete radical prostatectomy specimen is one of the strongest predictors of prostate cancer progression and a valid measure of cancer severity. However, it is unclear whether preoperative parameters, including biopsy Gleason pattern 4/5 carcinoma, may predict radical prostatectomy Gleason pattern 4/5 disease and, thereby, distinguish indolent from clinically significant cancer. MATERIALS AND METHODS: We prospectively obtained 101 consecutive radical prostatectomy specimens and processed them in whole mount fashion. In addition to total tumor volume, we determined tumor volume for each Gleason pattern. Biopsy tumor area was measured in a similar fashion. Univariate and multivariate analyses were performed to identify preoperative clinical and pathology parameters for predicting Gleason pattern 4/5 carcinoma on prostatectomy specimens. RESULTS: Biopsy Gleason score 7 or greater, Gleason pattern 4/5 carcinoma, perineural invasion and biopsy tumor area had statistically significant associations for identifying Gleason pattern 4/5 carcinoma on prostatectomy specimens. Logistic regression models for predicting any or greater than 10% Gleason pattern 4/5 carcinoma on prostatectomy specimens revealed that an area of pattern 4/5 disease of greater than 0.01 cm.2 on biopsy was the best single predictor with odds ratios of 15.0 (95% confidence interval 3.3 to 69.0, p = 0.0005) and 3.9 (95% confidence interval 1. 4 to 10.9, p = 0.009), respectively. For predicting any pattern 4/5 carcinoma on prostatectomy specimens a biopsy area of pattern 4/5 disease of greater than 0.01 cm.2 had only 38% sensitivity but 96% specificity. Similarly for predicting significant pattern 4/5 disease on prostatectomy specimens, defined as 10% or greater pattern 4/5, sensitivity and specificity for a biopsy area of greater than 0.01 cm.2 were 34% and 88%, respectively. Therefore, due to high false-negative rates these models had limited predictive value on an individual basis. CONCLUSIONS: Biopsy parameters such as Gleason pattern 4/5 carcinoma may provide adequate specificity for predicting clinically significant cancer, as defined by high grade Gleason patterns in the corresponding radical prostatectomy specimen. However, the accuracy of these parameters for predicting indolent cancer is limited by a prohibitive rate of false-negative findings.

Adenocarcinoma↗
PubMed2001

Bladder tumor detection at virtual cystoscopy.

PURPOSE: To investigate the utility of computed tomographic (CT) virtual cystoscopy in the detection of bladder tumors. MATERIALS AND METHODS: Twenty-six patients suspected or known to have bladder neoplasms underwent CT virtual and conventional cystoscopy. The bladder was insufflated with carbon dioxide through a Foley catheter. Helical CT of the bladder was then performed. The data were downloaded to a workstation for interactive intraluminal navigation. Two radiologists blinded to the results of conventional cystoscopy independently reviewed the transverse and virtual images, with consensus readings for cases with discrepant results. RESULTS: Thirty-six (90%) of 40 bladder lesions proved at conventional cystoscopy were detected with a combination of transverse and virtual images. Four (10%) of 40 bladder lesions, all smaller than 5 mm, were undetected. Transverse and virtual images were complementary, since six polypoid lesions smaller than 5 mm depicted on the virtual images were not seen on the transverse images. In contrast, areas of wall thickening were more readily appreciated on transverse images. CT with patients in both supine and prone positions was necessary, since seven (19%) and five (14%) of 36 lesions were seen only on supine and prone images, respectively. CONCLUSION: CT virtual cystoscopy is a promising technique for use in bladder tumor detection of lesions larger than 5 mm. Optimal evaluation requires adequate bladder distention with the patient in both supine and prone positions and interpretation of both transverse and virtual images.

Adult↗
PubMed2001

Analysis of three-dimensional Doppler ultrasonographic quantitative measures for the discrimination of prostate cancer.

OBJECTIVE: The purpose of this study was to determine whether several quantitative ultrasonographic measures have potential to discriminate prostate cancer from normal prostate and to determine the best combination of these measures. The true spatial distributions of cancer within the prostates studied were obtained histologically after radical prostatectomy. The relationship between Doppler ultrasonography and microvessel count was also investigated. METHODS: Three-dimensional Doppler ultrasonographic data were acquired from 39 patients before radical prostatectomy. The removed prostate was sectioned, and whole-mount hematoxylineosin-stained slides were used to identify all regions of cancer within each prostate. These histologic and ultrasonographic data were spatially registered. Doppler ultrasonographic measures were calculated within uniformly sized three-dimensional regions that were either entirely cancerous or noncancerous, and receiver operating characteristic analysis was performed on the results. Microvessel counts were made within each contiguous cancerous region and correlated with ultrasonographic measures. RESULTS: Color pixel density was the best simple measure for discriminating prostate cancer (accuracy, 80%). The mean power mode value (normalized mean power in color pixels) was inversely related to cancer with an accuracy of 1--normalized mean power in color pixels = 65% (low mean power is more cancerous). When color pixel density was combined with the normalized mean power in color pixels, its accuracy improved slightly to 84%. The peak microvessel count had a negative correlation with color pixel density as well as with cancer stage. CONCLUSION: Doppler ultrasonography does provide discriminatory information for prostate cancer, with color pixel density being the most promising measure.

Humans↗
PubMed2001

Pelvic recurrences post cystectomy: current treatment strategies.

Pelvic recurrence following cystectomy is a devastating problem for both physician and patient. Patients who recur locally usually do so within the first 2 years following surgery. Stage, grade, and possibly p53 status of the tumor are prognostic indicators for local failure. Patients with extensive disease at the time of diagnosis may benefit from adjuvant or neoadjuvant treatment to attempt to decrease the rate of recurrence. Treatment of patients with local failure should use a multimodality approach that includes systemic chemotherapy with or without local radiation therapy or surgery. Although rare, long-term survival can be achieved in selected patients.

Abdominal Neoplasms↗
PubMed2001

The natural history of lower urinary tract symptoms in black American men: relationships with aging, prostate size, flow rate and bothersomeness.

PURPOSE: Studies of lower urinary tract symptoms in men have been restricted to predominately white populations and these observations may not be generalized to black American men. A goal of the Flint Men's Health Study was to evaluate the prevalence of lower urinary tract symptoms in a community based sample of black American men. MATERIALS AND METHODS: We identified 721 eligible subjects after a 2-stage stratified sampling protocol of black American men residing in Flint, Michigan and an in-home interview. Of these men 364 (50%) completed the study protocol, including serum prostate specific antigen measurement, digital rectal examination, uroflowmetry and transrectal ultrasound. These men comprised our study group. Patients completed the American Urological Association (AUA) symptom and bothersomeness scores. Moderate to severe symptoms and impairment were defined as an AUA symptom score of greater than 7 and bothersomeness score of greater than 3, respectively. Data were stratified by 10-year age groups. RESULTS: Prostate volume increased, while the peak urinary flow rate decreased with increasing age (p <0.001). Total AUA symptom and bothersomeness scores were marginally associated with age (p = 0.08 and 0.01, respectively). Although only 8.2% of the men reported an enlarged prostate and 3% reported being on medical therapy for benign prostatic hyperplasia, moderate to severe lower urinary tract symptoms were reported by 39.6% and moderate to severe impairment was present in 35%. CONCLUSIONS: To our knowledge this is the first study to describe the prevalence of lower urinary tract symptoms and its associations with age, prostate size and peak flow rate in a black American population. A large proportion of the men in this study had from moderate to severe lower urinary tract symptoms, of whom many were undiagnosed and untreated. The AUA symptom score has the potential to identify these men and its validity in black Americans has now been established.

Adult↗
PubMed2001

Assessment of early continence recovery after radical prostatectomy: patient reported symptoms and impairment.

PURPOSE: Patients considering radical prostatectomy often inquire as to when they can expect to regain urinary continence. However, there is a paucity of patient self-reported data regarding the recovery of continence during the initial 3 months after surgery. Our objectives were to assess urinary continence changes early in the postoperative period and determine which of 2 commonly used definitions of continence more closely relate to patient reported urinary impairment. MATERIALS AND METHODS: A prospective study of 90 men with clinically localized prostate cancer who selected radical prostatectomy as primary therapy was conducted. Repeated measures of urinary continence as defined by 1) total urinary control, 2) the use of 1 or 0 pads daily, and 3) small or no problem with urinary function were obtained with a brief survey preoperatively and postoperatively. RESULTS: At 56 days after removal of urethral catheters, the actuarial rates of urinary continence recovery based on definitions 1 to 3 were 43%, 84% and 82%, respectively. The use of definition 2 for continence resulted in a 1.9 times higher actuarial rate for continence recovery when compared to definition 1 at 56 days (p <0.001). However, strong agreement was observed between definitions 2 and 3 (kappa = 0.69). CONCLUSIONS: Urinary control is recovered in a significant proportion of men who undergo radical prostatectomy during the initial 3 months. Continence rates will vary significantly based on the use of alternative definitions. The clinical practice of asking patients how many pads daily they use may be valid, as it corresponds well to the impairment they have.

Aged↗
PubMed2000

Benign prostatic glands at surgical margins of radical prostatectomy specimens: frequency and associated risk factors.

OBJECTIVES: Elevation of serum prostate-specific antigen (PSA) after radical prostatectomy for prostate cancer is considered a surrogate marker of therapeutic failure. The most likely explanation for early PSA failure is considered to be due to local recurrent disease, provided the patient had a nondetectable PSA level after radical prostatectomy. Others have recently suggested that benign prostatic glands located on the surgical margins may often lead to detectable PSA levels. We examined the frequency of benign prostatic glands at the surgical margins of radical prostatectomy specimens and the factors associated with this finding. METHODS: One hundred nineteen consecutive radical prostatectomies were performed by two experienced oncologic surgeons. Whole-mount sectioning of the prostatectomy specimens was performed at 3-mm intervals. Bivariate and multivariate analyses were used to determine which clinical and pathologic factors were associated with benign glands on inked surgical margins. RESULTS: Of the 119 cases, 13 (11%) had benign glands on the inked surgical margins. Four of these 13 had tumor on the inked margins. The remaining 9 cases (8%) were organ confined (pT2), with negative surgical margins. Benign glands were most often seen to involve the apex focally (7 of 9 cases). On bivariate and multivariate analyses, a high Gleason score and prostate gland volume were significantly associated with finding benign glands on the surgical margins. Only 2 of 86 patients with follow-up had PSA recurrence at 59 and 67 days and neither had benign glands on the inked surgical margins. CONCLUSIONS: The presence of benign prostatic glands identified on inked surgical margins was an infrequent occurrence in this consecutive series of 119 whole-mount prostatectomy specimens. When benign glands were identified, they most often consisted of 1 to 3 glands at the apex margin. These findings suggest that benign glands on surgical margins are an unusual cause of postoperative detectable PSA.

Follow-Up Studies↗
PubMed2000

Nephron sparing surgery for suspected malignancy: open surgery compared to laparoscopy with selective use of hand assistance.

PURPOSE: Laparoscopic nephron sparing surgery has been reported rarely, likely due to technical difficulty when using only laparoscopic instrumentation. Hand assisted techniques may facilitate the procedure in select cases while maintaining the benefits of minimally invasive surgery. We prospectively compared the laparoscopic with selective hand assistance and open surgical approaches to nephron sparing surgery for suspected malignancy. MATERIALS AND METHODS: We compared our initial 10 laparoscopic nephron sparing procedures for suspected malignancy, including 8 with hand assistance, in 9 patients (11 tumors) with 11 consecutive open surgical procedures for similar indications. Standard laparoscopic technique was used in cases of an exophytic mass with shallow penetration into the parenchyma. Otherwise hand assistance was used. Recovery data were obtained prospectively using self-administered questionnaires. RESULTS: Although mean operative time was 24% greater in the laparoscopic group, recovery was more favorable than in the open surgical group, as evidenced by 62% less parenteral narcotic use, 43% shorter hospital stay, 64% more rapid return to normal nonstrenuous activity, and improved pain and physical health scores 2 and 6 weeks postoperatively. In each group mean lesion diameter was 2.4 cm., 8 of 11 neoplasms were malignant and no margins were positive for malignancy. There were no conversions to open surgery and no major complications in the laparoscopic group. CONCLUSIONS: Laparoscopic nephron sparing surgery appears to have an advantage over open surgery in terms of patient recovery. Facilitation by hand assistance may make laparoscopic nephron sparing surgery a more widely available, minimally invasive alternative to open surgery for small, favorably located renal tumors.

Adult↗
PubMed2000

Bladder neck-sparing modification of radical prostatectomy adversely affects surgical margins in pathologic T3a prostate cancer.

OBJECTIVES: To determine whether the bladder neck-sparing (BNS) modification of radical retropubic prostatectomy (RRP) alters the likelihood of positive surgical margins and postsurgical prostate cancer recurrence. METHODS: Surgical outcomes, as measured by pathologic margin status and progression-free survival, were evaluated in 751 consecutive RRP cases, among whom 222 underwent BNS technique. To reduce selection bias, comparison of positive margin rates between BNS and standard RRP was stratified by pathologic stage. Differences in surgical margin rates were assessed using the chi-square test, and effects of bladder neck preservation on prostate-specific antigen (PSA)-free survival were assessed, using multivariable Cox proportional hazards analysis. RESULTS: The clinical stage, Gleason score, and preoperative serum PSA profiles were similarly distributed between patients undergoing standard RRP and those undergoing the BNS modification. Surgical margins in the unstratified entire cohort were positive at rates similar to prior reports (28% BNS, 27% standard RRP). However, stratification by pathologic stage revealed that among pT3a cancers, BNS surgery was associated with significantly higher rates of positive surgical margins than was standard RRP (47% versus 20%; chi- square = 6.32, P = 0.01). Differences in positive margin rates were not seen between the two groups at other pathologic stages. The adverse effect of BNS technique on pT3a surgical margins was associated with a trend toward an adverse effect on PSA-free survival (Cox proportional hazards P = 0.016). CONCLUSIONS: The BNS modification of RRP can be associated with an increased rate of positive surgical margins specifically in cancers that have focally penetrated through the prostatic capsule (pT3a), with an associated trend toward decreased PSA-free survival in this group. BNS surgery may, therefore, compromise the ability to completely remove a subset of cancers focally penetrating the prostatic capsule.

Aged↗
PubMed2000

Prospective assessment of patient reported urinary continence after radical prostatectomy.

PURPOSE: Reported urinary continence rates after radical prostatectomy vary. Although modifications of radical prostatectomy meant to improve outcome, such as nerve sparing or bladder neck preservation, are in widespread use, to our knowledge evidence to support these practices based on patient report is scant. We evaluated the potential effects of nerve sparing and bladder neck preservation on urinary continence after radical prostatectomy, and assessed the impact of various urinary continence definitions on the observed outcome. MATERIALS AND METHODS: We prospectively evaluated a cohort of men with prostate cancer who elected surgery with and without nerve sparing, and bladder neck preservation as primary therapy. A total of 482 men completed a brief urinary continence questionnaire preoperatively and postoperatively at a median followup of 18 months. Urinary continence was followed prospectively using the questionnaire and patient reported urinary continence recovery was based on 3 definitions of continence. RESULTS: Median time to continence recovery based on patient reporting was significantly shorter in the nerve sparing than in the nonnerve sparing group when continence was defined as no urinary leakage (5.3 versus 10.9 months, p <0.01). A multivariate model controlling for baseline factors revealed that significant predictors of continence outcome were preoperative continence, patient age, nerve sparing and the interaction of nerve sparing with age (p <0.05). The definition of urinary continence also affected outcome. CONCLUSIONS: The nerve sparing technique of radical prostatectomy was associated with improved recovery of urinary continence in an age dependent manner, whereas bladder neck preservation was not beneficial. Patient age and the sensitivity of the incontinence definitions, as reflected by the associated variable rates of preoperative baseline incontinence, are significant contexts for interpreting urinary function data after radical prostatectomy. These factors may partially explain the variation in continence rates in the literature.

Adult↗