[Elevation of total PSA after intravesical BCG instillations: granulomatous prostatitis or prostatic adenocarcinoma?]

The objective of this study was to evaluate the incidence of prostatic carcinoma in patients treated by intravesical BCG-therapy for superficial bladder cancer and presenting granulomatous prostatitis. The authors discuss the problems of interpretation of total PSA and the potential indications for prostatic biopsies in this population.

A retrospective study was performed on the cases of symptomatic granulomatous prostatitis observed among patients treated with intravesical BCG instillations between January 1997 and December 2006. A total of 153 men were treated for high-risk or intermediate-risk superficial bladder cancer according to the usual recommendations. The attenuated Connaught strain of BCG was used at a dose of 81 mg. Induction treatment consisted of six weekly instillations and was followed by maintenance treatment for a period of three years.

Six patients developed symptomatic granulomatous prostatitis (4% of cases). On average, this complication occurred after about the 10th intravesical instillation (6-13) of maintenance treatment. The mean total PSA at three months was 8 ng/ml (range: 5-11.6). Ultrasound-guided biopsies were indicated in view of the persistently elevated PSA level and confirmed the tuberculoid granulomatous lesion of the prostate in each case and revealed prostatic adenocarcinoma in two patients.

Prostatic carcinoma must be systematically excluded by ultrasound-guided biopsies in all patients with clinical granulomatous prostatitis and persistently elevated PSA three months after intravesical BCG instillations.