dr

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with a PSA level �4 ng/mL. We have not recommendedroutine biopsy unless the levels have been �10 ng/mL.Lee et al1 reported similar findings, backed by a biopsyemonstration of benign prostatic hyperplasia in a Ko-ean study of 707 men. Pinsky et al,2 in a prostate cancer

screening study, showed that the prostate volume had anindependent correlation with the PSA level, irrespectiveof the detection of malignancy. These findings are, in away, diametrically opposite the results of the presentstudy and others that have advocated biopsy for patientswith lower PSA levels.

Conflicting reports on the importance of an elevatedPSA level (lower values supporting malignancy andhigher values in benign high-volume prostates) inform usthat PSA measurement, although a sensitive and populartool in the screening of prostate cancer, still needs re-finement to be considered an ideal marker, owing to itslow positive or negative predictive value. In our attemptto detect clinically and radiologically unapparent pros-tate cancer using a marker that has yet to prove itsspecificity, it is important that we do not end up laudingourselves for “successfully” treating a disease that mightnever have surfaced during the patient’s lifetime.

Sunil P. Shenoy, M.S., D.N.B., M.Ch., D.N.B.Prashanth K. Marla, M.S., M.Ch.

Division of UrologyA. J. Institute of Medical Sciences

Kuntikana, Mangalore, Karnataka, India

Karunakara K. Adappa, M.D., D.A.Department of Anaesthesia

A. J. Institute of Medical SciencesKuntikana, Mangalore, Karnataka, India

References1. Lee SE, Chung JS, Han BK, et al. Relationship of prostate-specific

antigen and prostate volume in Korean men with biopsy-provenbenign prostatic hyperplasia. Urology. 2008;71:395-398.

. Pinsky PF, Kramer BS, Crawford ED, et al. Prostate volume andprostate-specific antigen levels in men enrolled in a large screeningtrial. Urology. 2006;68:352-356.

Reply by the Authors

TO THE EDITOR:

We appreciate the informative comments about our re-port. In Korea, a prostate-specific antigen (PSA) level of�4 ng/mL is considered an indication for prostate biopsy.However, many investigators have reported a high prev-alence of prostate cancer at lower PSA cutoffs. Most ofthese cancers were found to have pathologic featuresconsistent with clinically significant disease. Catalona etal1 reported that prostate cancer was detected in 73(22%) of 332 men who had undergone biopsy with a PSA

level of 2.6-4.0 ng/mL and normal prostate examination

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findings. Of the patients who underwent radical prosta-tectomy, 81% were found to have organ-confined disease,and only 17% had tumors that were possibly harmless, asdetermined by the cancer volume and tumor grade. Sch-roder et al2 evaluated prostate cancer diagnosed byscreening men in the Rotterdam section of the EuropeanRandomized Study of Screening for Prostate Cancer.Approximately 50% of the cancers detected at a PSAlevel of �4.0 ng/mL had aggressive features.

In our study, we enrolled men who had visited ourdepartment for a variety of reasons, including prostatecancer screening and voiding symptoms, regardless ofwhether the visit was primary or had been referred. Theclinical evaluations included prostate volume measure-ment with transrectal ultrasonography, digital rectal ex-amination, and determination of the serum total PSAlevel. From January 2008, a transrectal ultrasound-guidedprostate biopsy has been recommended for patients witha total PSA level of �2.5 ng/mL, irrespective of thedigital rectal examination findings or the prostate vol-ume. We do agree that PSA measurement, although asensitive and popular tool for screening for prostate can-cer, still has a long way to go in terms of being an idealmarker. However, the objective of our study was to de-termine the detection rate of prostate cancer using onlythe PSA level and, furthermore, to examine the possibil-ity of a lower PSA level as an indication for prostatebiopsy. The results showed a detection rate of prostatecancer of 21.8% at a PSA level of 2.5-4.0 ng/mL and therate of organ-confined cancer in the prostatectomy spec-imen was 91.4% at the same PSA level of 2.5-4.0 ng/mL.We believe these results show the possibility of using alower PSA level as an indication for prostate biopsy.

Hong Seok Kim, M.D.Seong Soo Jeon, M.D.

Department of UrologySamsung Medical Center

Sungkyunkwan University School of MedicineSeoul, South Korea

References1. Catalona WJ, Smith DS, Ornstein DK. Prostate cancer detection in

men with serum PSA concentrations of 2.6 to 4.0 ng/mL and benignprostate examination: enhancement of specificity with free PSAmeasurements. JAMA. 1997;277:1452-1455.

2. Schroder FH, van der Maas P, Beemsterboer P, et al. Evaluation ofthe digital rectal examination as a screening test for prostate cancer:Rotterdam section of the European Randomized Study of Screeningfor Prostate Cancer. J Natl Cancer Inst. 1998;90:1817-1823.

Bacille Calmette-Guérin andOcular Inflammations

TO THE EDITOR:

Bacille Calmette-Guérin (BCG) can be instilled into the

urinary bladder as immunotherapy against superficial

UROLOGY 77 (4), 2011