Macroscopic examination of prostatic specimens.

Accepted for publication 1 December 1994 Clinical context of prostatic disease Benign hyperplasia and adenocarcinoma of the prostate are common diseases; this Broadsheet is published at an opportune time as awareness, investigation and treatment of both diseases are changing. Up to 25% of men past middle age may need assessment and treatment of clinically benign disease.' Open surgery, involving enucleation of hyperplastic nodules, has been largely replaced by transurethral prostatectomy (TURP) with its lower complication rate. These latter specimens may also decline as other forms of treatment for hyperplasia (for example, stents, drugs, lasers, microwave therapy) prove their efficacy. In previous years finger guided transrectal or, more rarely, transperineal biopsies were performed on patients with symptoms of prostatism and in whom digital rectal examination (DRE) was suggestive of malignancy or in patients presenting with metastatic disease in whom a primary carcinoma was not clinically apparent. As up to 60% of patients with clinically apparent prostatic carcinoma are known to have metastatic disease at presentation, the value of a malignant diagnosis on biopsy was most commonly to permit palliation by hormonal therapy. Following the success in the USA in detecting prostate confined adenocarcinoma by annual DRE and the possibility ofdetecting impalpable carcinomas by elevated serum prostate specific antigen (PSA) and transrectal ultrasound (TRUS),2 the frequency of prostatic biopsies has increased in Britain. Fine needle aspiration cytology is an alternative to biopsy, but is not widely practised in Britain and is beyond the scope of this Broadsheet. In Britain controversy surrounds radical prostatectomy. Attention is drawn to the limited knowledge of the natural history of prostatic cancer, the absence ofvalid randomised studies on surveillance versus treatment (radical prostatectomy and radical radiotherapy) and the inadequacy of current clinical staging systems to distinguish gland confined (usually equated with curable) and locally extensive disease (in which postoperative tumour recurrence is likely). Nevertheless, some surgeons see radical prostatectomy as the only potential cure and more acceptable, as innovation in techniques has reduced the postoperative incidence of incontinence and impotence. The number of centres in which radical surgery is practised is still relatively small, but is increasing. The dissection of the prostate as a component of radical cystectomy has been described in a previous Broadsheet.3