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Many of the proposed methods have high computation load procedures and are hard to implement for real-time applications. We have developed a local spectral analysis method of the RF signal 1- 4 which allows a simple and rapid representation of the results.

The purpose of the present study was to compare in vitro the spectral ultrasound parameters with the histopathological findings of the radical prostatectomy specimens, evaluating the validity of the pro- posed method in discriminating neoplastic from non-neoplastic tis- sue.

MATERIAL AND METHODS The study was performed on 60 Figure 2. prostate glands of patients who had Image of a transverse scan plane a compared with a transverse whole undergone radical retropubic -mount section of the radical prostatectomy specimen b. prostatectomy for clinically localized prostate cancer. After the prostate was surgically removed, it was scanned in vitro using the FEMMINA Fast Echo- graphic Multiparametric Multi Image Novel Apparatus platform 5,6with a commercial echograph modified to give RF signal output AU3 Esaote.

The FEMMINA platform allows echo sig- nal acquisition and processing with a multi-image data representation. The scan procedure was repeated several times in different measure- ment conditions in order to verify the reproducibility and reliability of results.

Radical prostatectomy speci- mens were placed in a tank filled with physiological saline and held in the correct position by means of threads. The prostate was ultrasoni- cally scanned from the apex to the base at 2 mm intervals by moving the probe with a mechanical system Figure 1. Marking of reference section in order to preserve the correct anatomical orientation for comparison with RF acquired frames.

echographic acquired section. Special care was taken to location, or else for every time instant, the wavelet coef- preserve the correct anatomical orientation for compar- ficients were collected and the best-fitting fourth degree ison with RF acquired frames: three pins were inserted polynomial curve was calculated. into the gland in order to mark the same starting section The considered area was 3x50 points and it consisted of for echographic acquisition and histological slicing polynomials.

The histogram of coefficients of the Figures 2 and 3. Each section was microscopically area under study was evaluated. The third degree coeffi- examined and the tumour areas were demarcated with cient, named LE Local Estimatorwas extracted from an ink line and transferred onto paper to make a histo- each polynomial belonging to the area under considera- logical map.

For each radical prostatectomy specimen tion Figure 4. three areas showing prostatic cancer, BPH and normal The histogram was processed over a range with lower and tissue were compared. upper bounds of, respectively, minimum and maximum In order to preserve local information and to obtain values obtained from processing the entire gland, and it spectral images, time frequency transform is required. was subdivided into classes. From this histogram, the The system of wavelet transform was chosen for its most representative subset of values was extracted and noise immunity, its capability to recover the signal and mapped on a conventional B-mode through a chromatic its balanced compromise between time and frequency code Figure 5.

The study consisted in two stages: the first resolution 7. In particular, the results reported here step, carried out on ten sections referring to ten radical were obtained by Discrete Wavelet Packet Transform prostatectomy specimens where cancer had previously DWPT For each sight line of a B-mode image, we con- been diagnosed by histology, to set up the procedure for sidered the RF signal, which is decomposed by DWPT correlating the different spectral parameter distribution to into eight different spectral bands, and consequently the three different areas previously identified by the eight series of wavelet coefficients were calculated pre- pathologist; the second step, performed on all echograph- serving the space or time reference.

Masotti Figure 4. pared to non-neoplastic areas. Method for spectral parameter evaluation. Indeed, it was noted that the tumour and BPH areas exhibited Gaussian statistics, while normal tissue had a nearly uniform distri- bution throughout all classes Figure 6.

Thus, it was possible to differenti- ate normal from pathological tis- sue BPH and cancer. From the analysis of the his- tograms concerning BPH and tumour areas, it could be assumed that a range of classes exists which is mostly representative of the two pathologies. Spectral analy- sis carried out in the tumour areas generally gave values within class- es In order to evaluate the accuracy of the class range associated with cancers, we processed all echo- tion, was finalized to assess the sensitivity and specificity graphic scans of the sample studied.

The results were for cancer detection. visualized by a B-mode echographic image in which the area of interest was shown by means of a selectable chro- matic scale, the colour levels of which were proportion- RESULTS al to the population intensity of the classes researched After having processed all the prostatic glands under Figure 7.

study, a range of values from The specificity was invalidated by the fact tation of each class and discrimination among values that, in some of the cases studied, the tumour classes belonging to different classes.

The classes referring to overlapped with those of BPH Figure 8. As for the sen- neoplastic areas exhibited different distribution com- sitivity, we obtained three false negatives: two were due to the presence of cancer foci in Figure 5. BPH sites for which different class Representation of two different pathological areas by means of two different ranges were found.

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pseudocolour scales. This rise in incidence has been related to improvements in diagnostic procedures PSA levels, TRUS and increasing life expectancy. Different Wamble distribution for three different areas. Figure 7.

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random biopsies in order to achieve the correct diagno- Comparing between histological characterization and sis, with a significant increase in morbidity and costs. processed images of one reference section, marked Since the imaging of prostate cancer is currently limited with repere points. by the poor accuracy of systematic conventional grey- scale ultrasonography, in recent years research has focused on software developments to improve the exist- ing ultrasound technology, such as three-dimensional imaging, colour Doppler with or without ultrasound contrast agentspower Doppler and combined tech- niques three-dimensional contrast-enhanced power Doppler ultrasonography Garg et al.

In a small series of patients Hamper et al. In contrast, Sedelaar et al. Over the last 20 years, many researchers have proposed processing techniques to extract information about biological tissue microstructure or material prop- erties that are not yet conveyed in conventional echo- graphic B-mode images. All these techniques use radiofrequency echo signals to preserve information that is otherwise lost Figure 9. Masotti Figure 8. Current generation echographs uti- Histogram referring to all scans analysed in order to evaluate sensitivity lize signal envelope i.

Mode, B-Mode and M-Mode repre- sentations are based on the enveloped signal. By adopting this solution, the information contained in the RF signal is completely lost. Only recently, echographic systems, such as the General Electric System FIVE and Vivid VII, equipped with an ultrasonic RF output for research purposes, have been put on the general market. Previously, only a few academic research groups had access to vendor supplied engineer- ing mode interfaces adapted for modified commercial systems.

One example of this type of inter- face was the General Electric Extend option for GE Logiq that permitted access to raw beam- formed line data. Some fluency in relatively low level programming languages was required to use these earlier interfaces.

In order to preserve local informa- tion and to obtain spectral images, time frequency transform is needed. The wavelet transform has been chosen for its noise immunity, its capability to recover the signal and its balanced compromise between time and frequency resolution.

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In particular, the results reported Figure 9. here were obtained by Discrete Radiofrequency signal with two spectrum A e B related to two different signal Wavelet Packet Transform DWPT portions.

Two different local spectral shapes can be noted. and the final spectral parameters were determined. The statistical distribution of these parameters seems to be typical of prostate can- cer, BPH and normal prostatic tis- sue which are characterized by spe- cific class values.

In this study, spectral signal pro- cessing produces a final image where the tumour area is shown up by means of a chromatic code superposed on the B-mode repre- sentation. Eur Urol provided an encouraging confirmation with the histo- ; logical findings. Bogers HA, Sedelaar JP, Beerlage HP, de la Rosette JJ, Debruyne At present, a correlation between the Gleason score and FM, Wijkstra H, Aarnink RG. Contrast-enhanced three-dimension- the range of classes does not seem possible.

As the aim al power Doppler angiography of the human prostate: correlation of this study was to determine the presence of cancer, with biopsy outcome. Urology ; the minimum cost parameter was selected with the con- sequence being an incorrect evaluation of tumour vol- Shigeno K, Igawa M, Shiina H, Wada H, Yoneda T. The role of ume.

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This is possibly due to the fact that a single por- colour Doppler ultrasonography in detecting prostate cancer. BJU tion alone of all the information was considered: only a Int ; third order coefficient was taken into account and the Unal D, Sedelaar JP, Aarnink RG, van Leenders GJ, Wijkstra whole tumour structure was probably not represented. H, Debruyne FM, de la Rosette JJ. Three-dimensional contrast- Further in vivo studies are warranted to confirm the enhanced power Doppler ultrasonography and conventional exam- clinical utility of this promising technique in detecting ination methods: the value of diagnostic predictors of prostate can- prostate cancer.

BJU Int ; Takahashi S, Yamada Y, Homma Y, Horie S, Hosaka Y, Kitamura T. Masotti L, Biagi E, Granchi S, Breschi L. Metodo e dispositivo per clinical utility and limitations. Urology ; l'analisi spettrale di un segnale ecografico.

FIA27 Febbraio European Patent No. Garg S, Fortling B, Chadwick D, Robinson MC, Hamdy FC. US Patent, February 25, Staging of prostate cancer using 3-dimensional transrectal ultra- sound images: a pilot study. J Urol ; 2. Masotti L, Biagi E, Cerofolini M, Bertini A, Calzolai M, Bigagli A, Galardi L, Giovannucci C. Method for enhancing the diagnostic Hamper UM, Trapanotto V, DeJong MR, Sheth S, Caskey CI.

power of ultrasonic scanning system by using real time spectral Three-dimensional US of the prostate: early experience. maps, and device operating by said method. US Patent 6Radiology ; May 23, Sedelaar JP, van Roermund JG, van Leenders GL, Hulsbergen- 3.

Masotti L, Biagi E, Acquafresca A, Breschi L, Calzolai M, van de Kaa CA, Wijkstra H, de la Rosette JJ. Three-dimensional Facchini R, Giombetti A, Granchi S, Ricci A, Scabia M. Ultrasonic grayscale ultrasound: evaluation of prostate cancer compared with images of tissue local power spectrum by means of wavelet packets benign prostatic hyperplasia. Urology ; for prostate cancer detection. In Proc 26th Int Symp Acoust Imaging, ; 97 Lorenz A, Pesavento A, Scheipers U, Ermert H, Garcia-Schur- mann M, Sommerfeld HJ, Senge T, Philippou S.

Ultrasonic tissue 4. Biagi E, Calzolai M, Granchi S, Masotti L, Scabia M. Real-time characterization-assessment of prostate tissue malignancy in vivo processing of the radiofrequency ultrasonic echo signal for on-line using a conventional classifier based tissue classification approach spectral maps.

In Proc 24th Int Symp Acoust Imaging, ; 95 and Elastographic Imaging, IEEE Ultrasonic Symposium 5. Scabia M, Biagi E, Masotti L. Hardware and software platform for Scheipers U, Lorenz A, Pesavento A, Ermert H, Sommerfeld real-time processing and visualization of echographic radiofrequency HJ, Garcia-Schurmann M, Kuhne K, Senge T, Philippou S. IEEE Trans Ultrason Ferroelect Freq Contr ; Ultrasonic multifeature tissue characterization for the early 6.

Biagi E, Calzolai M, Capineri L, Granchi S, Masotti L, Scabia M. detection of prostate cancer, IEEE Ultrasonic Symposium FEMMINA: a fast echographic multiparametric multi-imaging Schmitz G, Ermert H, Senge T, Tissue-characterization of the novel apparatus.

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In Proc IEEE Ultrason Symp, ; prostate using radio frequency ultrasonic signals. IEEE Trans 7. Georgiou G, Cohen FS. Tissue characterization using the contin- Ultrason Ferroelect Freq Contr ; uous wavelet transform.

Part I: Decomposition method. IEEE Trans Lizzi FL, Feleppa EJ, Astor M, Kalisz A. Statistics of ultra- Ultrason Ferroelect Freq Contr ; sonic spectral parameters for prostate and liver examinations.

Watanabe H, Igari D, Tanahasi Y, Harada K, Saito M. IEEE Trans Ultrason Ferroelect Freq Contr ; Development and application of new equipment for transrectal ultrasonography. J Clin Ultrasound ; Feleppa EJ, Kalisz A, Sokil-Melgar JB, Lizzi FL, Liu T, Rosado AL, Shao MC, Fair WR, Wang Y, Cookson MS, Reuter VE, Heston 9. Sedelaar JP, Vijverberg PL, De Reijke TM, de la Rosette JJ, Kil PJ, WD. Typing of prostate tissue by ultrasonic spectrum analysis. Braeckman JG, Hendrikx JM.

Transrectal ultrasound in the diag- IEEE Trans Ultrason Ferroelect Freq Contr ; Correspondence: Alessandro Bertaccini, M. Orsola-Malpighi, Via P. Palagi 9 Bologna, Italy; E-mail: alessandro bertaccini. net - specuro1 orsola-malpighi. Objective: To evaluate the effect of levofloxacin LVX oral therapy on total serum prostate specific antigen PSA values in patients with histological prostatitis.

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In all the remaining patients prostate biopsy was repeated: pro- state cancer Pca was detected in 1 out of 8 patients with significant reduction of total PSA and in 4 out of 11 patients with no significant marker decrease. Conclusions: treatment with LVX significantly reduced PSA values in over half of the patients with asymptomatic prostatitis, elevated total PSA and normal DRE and urinaly- sis.

This approach could be applied in the ambulatory setting in order to increase the spe- cificity of total PSA testing, reducing the number of negative, unnecessary, prostate biop- sies. KEY WORDS: Prostate; Prostatitis; Prostate-specific antigen; Biopsy; Antibiotics; Levofloxacin. med in this range, are negative for Pca However, elevated serum concentrations of PSA are On this basis many authors tried to increase the specifi- founded both in patients with benign prostate hyper- city of PSA testing.

option in the management of patients with subclinical Total PSA serum concentration may be influenced by prostate inflammation.

acute prostatic flogosis, while the influence of subclini- Aim of this study was to evaluate the effect of LVX on cal inflammatory foci on elevation of the marker is still total PSA, administered orally once a day in ambulatory on debate.

A controlled, randomized, PSA response two weeks after the end of antibiotic open-label study evaluated in a cohort of 90 patients therapy. a 3 weeks administration of ofloxacin OFX, mg Follicolar chronic prostatitis per os bis in die comparing them with the biological x ; haematoxylin and eosin staining.

variations in untreated patients Significant varia- tions of mean PSA have been reported in this study only in patients treated with antibiotics 6.

A recent subset analysis from a multicenter double- blind active control clinical trial that compared levoflo- Figure 2. xacin LVX at a daily oral dosage of mg for 28 days, Interstitial chronic prostatitis with CPX, administered orally twice daily at a dosage of x ; haematoxylin and eosin staining. LVX accumulates into the prostate, achieving concentra- tions between 1. coli and administered orally once daily at a dosage of mg for 28 days shows comparable efficacy and tolerability as CPX administered orally twice daily at a dosage of mg for 28 days in the treatment of chronic bacterial pro- statitis Guercio, C.

Terrone, R. Tarabuzzi, M. Poggio, C. Cracco, R. Scarpa Figure 3. Figure 4. Chronic prostatitis with peri-tubular inflammatory Proportion of patients with significant decrease of PSA after infiltration x ; haematoxylin and eosin staining. therapy with levofloxacin mg per os once a day. The remaining 11 patients The non parametric Mann-Witney tant marker for Pca. However it is well known that other U test was performed for the comparison. Statistical analysis serum levels of the prostatic antigen.

was performed using the Statistica for Windows softwa- Particularly, when DRE is normal and total PSA is bet- re 5. Negative prostate biopsies for Pca often show presence RESULTS A total of 26 consecutive, outpatients patients were Figure 5.

Total PSA serum concentration nor- 8 Median value malized in 7 out of 15 patients The remaining 6 8 patients and with histological signs of prostatic inflammation, In order to reduce the number of negative biopsies, dif- reducing the number of negative, unnecessary, prostate ferent authors explored the effects of 3 or 4 week anti- biopsies. biotic therapy with fluoroquinolones on total PSA in Cost-effectiveness analysis of routine screening for sub- patients with clinical evidence of acute or chronic pro- clinical chronic prostatitis i.

However, if symptomatic prosta- lacking. Prospective, well designed studies are awaited titis, either acute or chronic, represent a definite clinical in order to clarify if a therapeutic protocol including condition whose role in increasing total PSA is now well fluoroquinolones, is cost efficacious and well tolerated recognized, studies on the influence of chronic asymp- in patients with normal DRE and elevated PSA compa- tomatic prostate inflammations on variations in PSA red with procedures that include prostate biopsies or values are still few.

Men with chronic prostatitis fre- monitoring of the individual biological variations of quently show perineal pain and lower urinary tract total PSA. Thus this therapeutic approach avoi- 1. Mettlin C, Jones GW, Avarette H, Gusberg SB, Murphy GP. Cancer ; Asymptomatic patients for prostatitis or urinary tract 2.

AUA: American Urological Association policy statement: early infections, with normal DRE and urynanalisis, represent detection of prostate cancer and use of transrectal ultrasound.

a group of patients of special interest because frequently Baltimore: may present abnormal levels of total PSA, whose causes are difficult to understand and suspected presence of 3. Catalona WJ, Richie JP, Ahman FR et al. Comparison of digital inflammatory foci may be one of these. rectal examination and serum prostate specific antigen in the early Our study has to be considered explorative and, in detection of prostate cancer: results of a multicenter clinical trial of agreement with previous studies on this subject, show men.

J Urol ; that also subclinical chronic prostatitis may have a role 4. Keetch DW, Catalona WJ, Smith DS. Serial prostatic biopsies in in rising total PSA and its treatment with fluoroquinolo- men with persistently elevated serum PSA values. J Urolnes may decrease and normalize the plasma level of the marker.

The individual, although not frequent, biological 5. Brawer MK. Prostate specific antigen: current Status. Gion M. Il PSA: parametro chiave nel trattamento del cancro deration, at least in large sample size cohort studies. A prostatico.

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In Intramed, Il carcinoma della prostata. controlled, randomized, open-label study analized the Milano: biological variations of serum concentrations of total PSA comparing them with the variations caused by 7. Prostate Specific Antigen. New York: Marcel Dekker three weeks with OFX mg per os bis in die in a Inc. DRE, negative urocoltures and a history of UTI and Effect of verification bias on screening for prostate cancer by meas- without clinical evidence of prostatitis. Significant urement of prostate-specific antigen.

N Engl J Med ; variations of mean total serum PSA have been repor- ted only in patients treated with antibiotics 6. Nadler RB, Humphrey PA, Smith DS, Catalona WJ, Ratliff TL. J Urol; criteria for prostatic biopsy, can be modified by anti- biotics in the patients with no evidence of prostatitis Lorente JA, Arabgo O, Bielsa R, Cortadellas, Gelabert-Mas A.

and with history of UTI. Scarpa els in patients with biochemical criteria for prostate biopsy and previ- Schaeffer AJ, Wu S-C, Tennenberg AM, Zadeikis N. Levofloxacin ous lower urinary tract infections. Intern J Biol Markers ; and ciprofloxacin in the treatment of chornic bacterial prostatitis lower serum prostate specific antigen.

J Urol ; 4 Suppl Potts JM. Prospective identification of national institutes of Abs No health category IV prostatitis in men with elevated prostate specif- ic antigen.

J Urol ; Langtry HD and Lamb HM. Its use in infection of the respiratory tract, skin, soft tissue and urinary tract. Drugs Ascoli R, Galuffo A, Lupo A, Di Gregorio L, Allegro R, Serretta ; V, Messina G, Pavone Macaluso M. Modificazioni del PSA dopo terapia antibiotica in pazienti candidati alla biopsia prostatica.

Bundrick W, Heron SP, Ray P et al. Levofloxacin versus Congresso Nazionale Societa Italiana di Urologia: Poster C; ciprofloxacin in the treatment of chronic bacterial prostatitis: a ran- abstract book pg. Urol ; Corrispondenza: Carlo Terrone, M.

Luigi, Regione Gonzole 10 -Orbassano, Torino, Italy ; E-mail: carlo. terrone unito. Achim M. Loske2, Jorge Gutierrez1, Eugenio Di Grazia1, Francisco Fernandez2 1 Nuevo Hospital Civil, Universidad de Guadalajara, Mexico; 2 Centro de Fisica Aplicada y Tecnologia Avanzada, Universidad Nacional Autonoma de Mexico, Mexico.

Introduction: It seems that vasoconstriction induced by 12 Kv shock waves reduces kidney lesions caused by subsequent application of 24 Kv shock waves. The lowest Summary shock wave voltage to induce this protective effect is not known yet and may be lower than the common energy setting of commercial lithotripters.

Because of this we pro- pose the application of shock waves as a tissue protecting method. Materials and methods.

Preliminary pressure measurements were performed on an experimental umnodified HM3 lithotripter at 12 and 24 Kvusing a 20 ns rise time needle hydrophone connected to a MHz digital oscilloscope.

Ten pressure records were obtained at different aging of the spark plug. A new spark plug was used for each voltage. Pressure measurement were also per- formed on a Tripter compact lithotripter at 6 positions along the focal axis, starting at F2 and moving away from the reflector, using maximum voltage and capacitance 22 Kv, HI The position on the focal axis of the Tripter Compact with the same pressure as measured at 12 Kv on the HM3 at F2 was chosen as the prophylactic treatment spot PTS.

In vivo pressure measurement were done on the Tripter Compact placing the needle hydrophone inside the lower pole of the right kidney of an anesthetized healthy 25 kg female pig. Measurements were done at the same positions mentioned above, without moving the hydrophone, inside the pig.

For both in vitro and in vivo measurements, the radiopaque hydrophone was aligned with the focal axis, using the fluoroscopy system of the lithotripter. Results: The mean positive pressure peak at the second focus of the HM3 lithotripter was 64 and mV, at 12 Kv, respectively. Coefficients of variations were 0. No significant pressure differences were detected below and discharges with the HM3 and the Tripter compact, respec- tively.

Conclusions: Prophylactic administrations of out-of-focus shock waves may reduce tissue damage during SWL. Experiments in vivo are underway in order to prove this hypothesis.

KEY WORDS: ESWL; Lithotripsy; Stones. Nevertheless, lished inshowing that shock waves reduce both intrarenal and subcapsular hematoma have been found glomerular filtration rate GFR and renal plasma flow after SWL in a high percentage of cases examined. RPF in pigs 6. Organs adjacent to the kidney are usually unaffected.

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A few years later, Willis et al. Research is Germering, Germany lithotripter, RPF appeared to be still necessary to define techniques that minimize tissue independent of the voltage between 12 and 24 kV.

Loske, J. Gutierrez, E. Di Grazia, F. Fernandez pole Figure 1a did not cause hemorrhagic lesions but amount of shock waves at 24 kV to the other pole. induced vasoconstriction. They also examined lesions in Massive hemorrhagic injury occurred in kidneys treated upper and lower poles of kidneys after shock only in one pole at 24 kV.

Kidneys previously treated waves at 12 kV to one pole, followed by the same with shock waves at 12 kV showed little to no hemorrhagic tissue damage. It seems that vasoconstric- Figura 1. tion induced by the application of 12 kV shock waves a Prophylactic treatment with shockwaves focused at reduced bleeding and lesion development caused by the lower pole. b Prophylactic out-of-focus treatment subsequent application of 24 kV shock waves. The low- with shockwaves focused outside the kidney.

At the est shockwave energy level voltage to induce this pro- prophylactic treatment spot PTS the pressure, genera- tective effect is not known yet and may be lower than ted on a Direx Tripter Compact lithotripter at maximum the minimum energy commercial lithotripters.

Because energy, is equivalent to the pressure generated at F2 on of this, we propose the out-of-focus application of shock an unmodified Dornier HM3 lithotripter at 12 kV.

waves as a tissue-protecting method. Nevertheless, our group will also test the methods described here on a piezoelec- tric lithotripter. Electrohydraulic lithotripters induce shock waves by electrical breakdown of water between two electrodes, located at the focus FI closest to a rigid para-ellipsoidal reflector Fig. Shock waves are reflected off the reflector and concen- trated at the second focus F2.

Several hundred shock waves are needed to completely disinte- grate the stone. Frequencies range from a few hundred kHz to a few hundred MHz. Application of out-of-focus shock waves Application of out-of-focus shock waves is based on the fact that the protective effect of low energy shock waves may be enhanced if a larger volume of the kidney is treated with these prophylactic waves.

Our technique may also open the possibility to treat the kidney at ener- gies lower than the energy obtained at F2 using the low- est voltage setting of commercial lithotripters.

As shown in Figure 1b, during out-of-focus prophylactic treatment the lower pole is located at the focal axis, a few cen- timeters away from F2. MATERIALS AND METHODS Preliminary pressure measurements were performed on an experimental unmodified HM3 lithotripter 8 at 12 and 24 kVusing a 20 ns rise time needle hydrophone Imotec GmbH, D Wurselen, Germany connected to a MHz digital oscilloscope Tektronix, Inc.

Table 1. RESULTS Pressure measurements were also performed on a The mean positive pressure peak voltage measured on Tripter Compact Direx Medical Systems Ltd. Coefficients of variation standard deviation using maximum voltage and capacitance 22 kV, HI divided by average were 0. The hydrophone was fastened inside a specially Results obtained with the Tripter Compact are shown in designed 40 x 36 x 35 cm Lucite test tank.

One side Table 1 in vitro and Table 2 in vivo. of the tank had a rubber membrane, used as an acoustic No significant pressure differences were detected below window by placing it in contact with the latex mem- and discharges with the HM3 and the Tripter brane of the lithotripter.

Due to the rubber membrane, Compact, respectively. F2 Figure 1b was chosen as the prophylactic treatment spot PTS. Measurements were done at the same generated by the Tripter Compact at its maximum ener- positions mentioned above, without moving the gy, 30 mm away from F2. This position was defined as hydrophone inside the pig.

For both in vitro and in vivo the PTS. This may be due to cavitation generated lithotripter. inside the body, along the shockwave path. Table 2. Chaussy C, Schmiedt E, Jocham D, et al.

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First clinical experience, the protecting therapy reported by other authors with with extracorporeally induced destruction of kidney stones by shock our out-of-focus therapy. Pigs from group 1 are treat- imfperu.coms. J Urol ; ed with shock waves 22 kVfocused on the 2. Coleman M, Saunders JE. A review of the physical properties and bio- lower pole of one kidney.

A second group of pigs is logical effects of the high amplitude acoustic fields used in extracorpore- receiving the same treatment but is previously treated al lithotripsy. Ultrasonics ; with prophylactic, shock waves generated at 22 3.

Delius M. Medical applications and bioeffects of extracorporeal shock kV, positioning the lower pole of the kidney at the PTS waves. Shock Waves ; Figure 1b. A third group of pigs is used as shams. Evan AP, Willis LR, Connors BA, et al, Shock wave lithotripsy- Treated and non-treated kidneys are being removed at induced renal injury. Am J Kidney Dis ; the end of the experiment to evaluate histological damage.

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Evan AP, Willis LR, Lingeman JE, et al. Renal trauma and the risk of long term complications in shock wave lithotripsy.

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Nephron ; 78,1 6. Willis LR, Evan AP, Connors BA, et al. J Urol ; may reduce tissue damage during SWL. Experiments are 7. Willis LR, Evan AP, Connors BA, et al. The application of low-ener- underway in order to prove this hypothesis. gy shock waves to one renal pole prevents hemorrhagic injury induced by high-energy shock waves in the other pole. In: Bettucci A E Proceedings of the 17th International Congress on Acoustics, vol. ISBN X. The authors would like to acknowledge Direx de Mexico 8.

Locke AM, Mendez A, Fernandez F, et al. Conversion of an HM3 for providing the spark plugs for this study. lithotripter into a research device. J Endourol Correspondence: Eugenio Di Grazia, M.

Materials and Methods: We investigated consecutive asymptomatic men, mean age Each patient was planned to undergo transrectal ultrasound-guided systematic 8 step scheme and hypoechoic lesion directed biopsies. Immediately at the con- clusion of the procedure and a week later, patients completed ten point visual analogue scale scores VAS about the pain and morbidity.

Results: Patients who received local anaesthesia had a lower VAS score compared with the group without lidocaine during the biopsy regarding pain during and after biopsy and on the duration of pain. At day 7-follow-up differences of VAS scores resulted similar. Lidocaine injection caused no local or systemic adverse effects. Conclusions: The periprostatic anaesthesia represent a simple, safe, rapid and easy to imple- ment procedure and significantly reduces pain and morbidity associated with prostate biopsy.

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Therefore it is recommended in patients at higher risk of prostate cancer who require a re- biopsy during lifetime. KEY WORDS: Local anaesthesia; Pain; Transrectal ultrasound; Periprostatic plexus block. Pain related to the procedure result be signifi- cant and related to needle puncture of the prostatic cap- sule and to positioning and maintaining the probe in the MATERIALS AND METHODS rectum 1. biopsy, pain and discomfort associated with this proce- We randomly assigned patients in two groups, submit- dure results more intense 3,4.

Damiano, F. Cantiello, R. Sacco, R. Autorino, M. de Sio, M. At the end of the procedure and seven days following Systematic 8 cores bioptic scheme. procedure, pain and discomfort were evaluated using a questionnaire with a visual analogue score VAS scale for pain characteristics and complications 6. Patients were informed regarding the use of anaesthetic only after questionnaire compilation. AH MID MID AH RESULTS APEX APEX Both groups resulted similar regarding age A lower VAS score during mean VAS 2.

Similar differences were record- AX: peripherial zone lateral border at mdgland anterior horn ed after seven days from procedure pain during biopsy mean VAS 2. Complications related to biopsy following three days after biopsy, and a fleet enema two hour procedure and a week later resulted similar between before biopsy.

intervals and comparable in both groups Table 2. Anticoagulation or aspirin therapy were stopped 1 week before biopsy. cedure and without anaesthesia.

Anyway, in our experi- Periprostatic infiltration was performed using a ence and in several studies many patients reported pain gauge needle through the biopsy guide and positioned during procedure, specially with extensive bioptic on each side basero-laterally between the base of the schemes 1, 2, 5.

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Crundwell 7 reported mild to mod- prostate and seminal vesicles. So a significant dle withdrawal toward prostate apex. number of patients experienced pain during prostate No epinephrine was mixed with lidocaine. At the end of biopsy and anaesthesia resulted helpful to them. the procedure, the ultrasound probe was withdrawaled Several anaesthetic procedures has been described, and for a mean time of 10 minutes, and then re-positioned among them periprostatic nervous block, as reported for prostate biopsy with the use of an automated gun first by Nash 1 and adopted in this study, results a safe, with a 18 gauge 22 mm core Tru-Cut needle.

simple and easy to perform procedure. Pain VAS score between anaesthesia or not groups P-value. Following biopsy A week later Visual analogue score vas lidocaine no lidocaine no Pain during probe insertion 0.

Complications VAS score between anaesthesia or not groups P-value. Following biopsy A week later Visual analogue score vas lidocaine no lidocaine no Hematuria 3. then sacral and toracolombar spinal centres. Nash PA, Bruce JE, Indudhara R, Shinohara K. Transrectal ultra- 9.

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sound guided prostatic nerve blockade eases systematic needle biop- Soloway 10 described a modified version of the sy of the prostate. J Urol ; periprostatic nerve block, involving instilling local 2. Eskew LA, Bare RL, McCullough DL. Systematic five region anaesthetic agent into the periprostatic nerve with a prostate biopsy is superior to sextant method for diagnosing carci- bilateral injection at the junction of the base of the noma of the prostate.

J Urol ; prostate and seminal vesicles and also in two additional points, one beside the apex and one in between the apex 3. Stewart CS, Leibovich BC, Weaver AL et al. Prostate cancer and the base. diagnosis using a saturation needle biopsy technique after previous The rationale of this approach should be the detection negative sextant biopsies.

J Urol ; of a more intense pain when bioptic cores are taken at 4. Stirling BN, Shockley KF, Carothers GC, Maatman TJ. Pain per- the level of prostate apex 11, In a randomized con- ception during transrectal ultrasound guided prostate needle biopsy: trolled trial, Schostak 13 reported that infiltration at an objective analysis of local anesthesia use.

Prostate Cancer the apex gave the lowest pain score. Prostatic Dis, ; The use of lidocaine is related to its characteristics, as the rapid onset and the duration h useful for biop- 5. No epinephrine was mixed to M. Are re extended biopsies necessary to improve prostate cancer the lidocaine to prolong the anaesthetic effect. Prostate Cancer Prostatic Dis. Questionnaire based evalu- ous studies, even if the TRUS is itself considered cause ation of prostate biopsy complications comparing different bioptic of patient discomfort.

Arch Ital Urol Androl ; Our study showed a lower pain score related to probe insertion and positioning in rectum with no significant 7. Crundwell MC, Cooke PW, Wallace DM. Br J Urol ; 8. Irani J, Fourier F, Bon D et al. Patient tolerance of transrectal ultrasound-guided biopsy of the prostate. Hollabaugh RS, Dmochowski RR, Steiner MS et al. sent a simple, safe and easy to perform procedure and Neuroanatomy of the male rhabdosphincter.

Urology ; our data report a significant reduction of pain. Soloway MS, Obek C. Periprostatic local anesthesia before nociceptive and sensorial anaesthesia, reducing pain ultrasound guided prostate biopsy. J Urol ; related to the bioptic procedure. No patient presented complications related to the use of Kaven I, Mabjeesh NJ, Matzkin H.

Randomized prospective anaesthesia and all referred to repeat the procedure study of periprostatic local anesthesia during transrectal ultrasound without hesitancy, if necessary.

Complications resulted guided biopsy. Jones JS, Ulchaker JC, Nelson D, Kursh ED, Kitay R, Angie S, Periprostatic Horvat M, Klein EA, Zippe CD. Periprostatic local anesthesia elim- nerve block gives better analgesia for prostatic biopsy.

Br J Urol inates pain of office-based transrectal prostate biopsy. Prostate ; Cancer Prostatic Dis ; Leibovici D, Zisman A, Seigel YJ, Sella A, Kleinmann J, Lindner Schostak M, Panick M, Goessl C, Chistoph F, Miller K. Local anestesia for prostate biopsy by periprostatic lidocaine Optimizing local anesthesia for systematic tenfold prostatic biopsy.

injection: a double-blind placebo controlled study. J Urol ; J Urol ; Correspondence: Rocco Damiano, M. Campanella - Catanzaro, Italy; E-mail: damiano unicz. Alessandro Zucchi1, Ettore Mearini1, Elisabetta Costantini1, Carlo Vivacqua1, Vittorio Bini2, Luigi Mearini1 1 Urology Department, University of Perugia, Italy; 2 Paediatrics and Gynaecology Department, University of Perugia, Italy.

Objective: To evaluate the reliability of measurements obtained using standard imaging techniques ultrasound and CT scan vs pathological measurements and the relationship Summary between clinical staging and the choice of the type of surgery. We also analyzed the rela- tionship between cancer parameters size, site, type of surgery and prognosis. Materials and Methods: A retrospective analysis was conducted to examine a series of patients with kidney cancer, all of whom underwent preoperative staging with abdominal ultrasound scan US and CT scan.

Results: The comparison between imag- ing and pathological findings revealed a good classification of tumor dimensions between the two imaging methods and pathologic size correlation coefficients all over 0. We observed that the range in which the measurement error is lowest is over 6 cm: in other words, when smaller lesions are present there is a greater likelihood of committing measurement errors. As expected, logistic regression analysis shows that the size of the tumors significantly influenced the surgical approach and survival at five years follow-up.

Conclusions: The imaging methods used in clini- cal staging of renal tumors currently allow us to select the most appropriate surgical option with a certain amount of confidence. Tumor size continues to be one of the most important factors in prognosis and it can influence both the surgical approach and cancer-specific survival.

KEY WORDS: Renal tumors; Clinical staging; Surgical approach. Radical nephrectomy con- abdominal ultrasound scan and CT scan, with measure- tinues to be the treatment of choice for renal tumors, ment of major diameter; regardless CT scan, width of although there is increasingly frequent reliance on CT slides were identical in all patients, and we chose the nephron sparing surgery, elective or mandatory, particu- largest diameter reported by the radiologist.

According to clinical staging and intra-operative pat- The choice between radical or conservative surgery is tern, ninety patients underwent radical nephrectomy, inseparably linked to preoperative staging. The objective while conservative surgery was performed on fifty. of this study is to evaluate the reliability of the measure- Nephron sparing surgery were performed for absolute ments obtained using imaging techniques and if they have indication in 10 patients 3 cases of single kidney, 3 impact on the choice of surgery; and finally if site, tumor cases of bilateral involvement and 1 case with a con- size and type of surgery affect cancer-specific survival.

Zucchi, E. Mearini, E. Costantini, C. Vivacqua, V. Bini, L. Mearini Table 1. Using this model, through Correlation coefficient 0. All statistical analyses were carried out with SPSS v PS-US: pathological-size-ultrasound; PS-CT: pathological- 6. tions and counter-indications age, performance status, co-morbidities, renal functionand after an informed RESULTS consensus.

All patients were reassessed according to TNM During conservative surgery we avoided the use of vas- staging. cular occlusion we used it only in cases in which is Clinical staging showed pts with T1 disease helpful during haemostasis. plasia, valuing its largest diameter. Mean US diameter was 4. There Altman test 3. In this case, the correlation coefficient are no significant differences with regard to either the indicates only the correct reclassification of tumor size.

frequency of tumor location in the three sites upper We used the Bland-Altman test that provides for the lim- pole, mesorenal, lower pole or the side involved. Chi-square and pT4 in only one patient 0. test instead was used to compare the frequencies of Histological examination revealed cases of clear cell localization of renal tumors.

carcinoma, 21 cases of granular cell carcinoma, 6 cases To determine if and to what extent the size of the tumor of papillary adenocarcinoma, 2 cases of sarcomatoid car- measured with the three techniques and the site affect cinoma and 9 cases of oncocytoma. the surgical option, a model of multiple logistic regres- Mean specimens diameter was 4. cm, SD 3. two standard deviations, as envisaged by the Bland- Table 2.

Superior pole Mesorenal Inferior pole PS-US PS-CT PS-US PS-CT PS-US PS-CT Mean of differences cm Percentage and absolute values of limits of agreement subdivided according to tumor size. A good classification was also noted in Statistical analysis of error of measurement showed that terms of tumor size between the two imaging methods this error is distributed over the entire range of the mea- and pathologic size, with correlation coefficients that all surements with a trend in the value of the limits of exceeded 0.

This comparison between pathologic size and US measure- interpretation of numeric data is commonly used in ment and of 2. however, according to our experience, the range in Table 2 lists the same statistics divided according to which the measurement error was lowest is for lesions tumor location.

The worst results were observed with over 6 cm This regard to the staging of the upper pole. means that for smaller lesions there is a greater possibil- With regard to the evaluation of the limits of agreement ity of committing measurement errors. alone, divided according to tumor size Table 3the With regard to choice of the type of surgery - radical or best values were noted with lesions with a diameter of conservative - logistic regression analysis shows that the more than 6 cm both for PS-US and PS-CT.

location of the tumor does not significantly affect this The site of the tumor is not correlated with the type of choice. The same type of analysis was applied to the model In terms of cancer-specific survival, the results clearly using survival as a dependent variable and age, site, show that only tumor size clinical or pathological mea- tumor size and type of surgery as independent variables.

surements were negatively and significantly correlated The results showed that only tumor size was negatively with outcome, at both the two- and five-year follow-up. and significantly correlated with survival at both two We adopted a probability approach to the study of sur- and five years of follow-up.

vival with respect to the retrospective one commonly used, because it yields a more fine-tuned evaluation of the impact of tumor size on outcome 7, 8. logical diameters respectively showed a mean of differ- ences equivalent to 0. Nevertheless the cm, with ranges of error that were also higher 3 - 4 indications that can be drawn from these studies allow cm us to choose the most appropriate surgical option with a Similar results were obtained by repeating the test for certain amount of confidence, even if there is a good cor- each tumor localization site upper pole, mesorenal and relation between clinical and pathological size.

lower pole ; in this case, the worst limits of agreement Naturally, the introduction of new diagnostic imaging were noted for the upper site approximately 3 cm methods such as the helical CT and the 3D-CT may offer and this could be explained by the fact that the radi- additional information thanks to the accuracy of the ographic margins of the upper pole are often masked by anatomic details that are displayed.

Stefani morgan anal

As a result, this may adrenal gland, diaphragm, liver and spleen 5. These offer better indications for the choice of conservative results are not confirmed by other authors as Irani 4. Mearini Tumor size continues to be one of the most important 4. Irani J, Humbert M, Lecocq B, Pires C, Lefebvre O, Dore B.

factors in prognosis. Renal tumor size: Comparison between Computed Tomography and This can affect both the surgical approach and the long- surgical Measurements. Eur Urol ; term results evaluated as cancer-specific survival.

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Herr HW. Radiographic vs surgical size of renal tumors after partial nephrectomy. BJU International ; 6. Herr HW, Lee CT, Sharma S Hilton S. Teigen EL, Newhouse H. Imaging renal masses. Curr Opin Urol my. Urology ; ; 7. Fergany AMR F, Hafez KS, Novick A. Long-term results of 2. Uzzo RG, Novick A. Nephron sparing surgery for renal tumors: nephron sparing surgery for localized renal cell carcinoma: 10 indications, techniques and outcomes.

J Urol ; years of follow-sup. J Urol ; 3. Bland JM, Altman DG. Statistical methods for assessing agree- 8. Kinouchi T, Saiki S, Meguro N, et. Impact of tumor size on the ment between two methods of clinical measure.

Lancet ; I, clinical outcomes of patients with Robson stage I renal cell carcino- ma.

Cancer ; Corrispondenza: Luigi Mearini, MD, Urology Dept. Prostatic calculi occur very often in men, but exceptionally they cause an almost total destruction of the prostatic parenchyma.

Preferred treatment in order to obtain com- Summary plete resolution is either transurethral resection or suprapubic simple prostatectomy. We report for the first time a radical prostatectomy as a unique chance for huge pro- static stones in a years old man with severe urinary symptoms.

We perform a retro- pubic radical prostatectomy using a nerve sparing technique. There were no intraoperative or postoperative complications. Though radical prostatectomy is an invasive approach to treat a young man affected by prostatic stones and without prostate cancer, we chose to perform it because of the impossibility to obtain complete recovery with transurethral or suprapubic sim- ple prostatectomy.

KEY WORDS: Prostatic stones; Prostatitis; Prostatism; Radical prostatectomy. cating calculi; hypoechogenic areas were also detected. Treatment is either transurethral resection or suprapubic NMR showed a reduced prostatic parenchyma with three prostatectomy. Radical prostatectomy for diffuse prosta- vacuolated formations 5, 4 and 3 cm in diameter; two con- tic calcifications has never been reported.

tained a corpuscolate fluid with calcified formations and the third one three large stones. The prostatic capsule was thinned and partially calcified at NMR.

Lymph nodes were CASE REPORT normal; the bladder wall was thickened.

As the entire pro- A 56 years-old male patient presented in August state was almost destroyed and calcified we opted for a with fever, dysuria, painful micturition, decreased stream radical retropubic prostatectomy using a nerve sparing and perineal pain. He was unable to sit down. The years technique. Transurethral resection of the prostate or supra- earlier the patient had undergone meatoplasty for meatal pubic simple prostatectomy were unlikely to be successful.

urethral stenosis. Before surgery he had several episodes of At prostate dissection 38 calculi of 25 g total weight were prostatitis with perineal pain and fever; prostatic ultra- found. Histology reported chronic phlogosis. The postope- sound scans had shown gross calcifications in both pro- rative period was uneventful and four months later trans- static lobes and around the bladder neck; the capsule was rectal ultrasound confirmed no stones were present.

At the cystourethrometrogram voiding time, seve- ral vacuolated dilations filled with calcified formations, had been observed. sters 1. Add it to your IMDbPage. Find out more at IMDb Pro.

How Much Have You Seen? How much of Stefani Morgan's work have you seen? See more awards. Known For. Debbie Does Dallas Again Debbie. Illicit Andi. Tera Goes Gonzo Actress.

Show all Hide all Show by Job Year Rating Number of Ratings Genre Keyword Edit. Jump to: Actress Self Archive footage. Hide Show Actress 24 credits. Hide Show Self 9 credits. Again TV Series Self - Vivid Girl - Climax Self - Vivid Girl. Show all 7 episodes. Self - Vivid Contract Girl. Hide Show Archive footage 4 credits. Edit Personal Details Other Works: Was a Vivid Girl trademark for Vivid Entertainment.

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Publicity Listings: 1 Interview 1 Pictorial See more. Alternate Names: Steffani Morgan Stephani Morgan Stephanie.

Height: 5' 10" 1. Edit Did You Know? Trivia: She is the mother of a child. Star Sign: Scorpio.

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