This Month in Clinical Urology

Article Outline

• Long-Term Effects of Lithotripsy on Renal Function and Blood Pressure
• Impact of Treatment Choice for Localized Prostate Cancer on Response to Phosphodiesterase Inhibitors
• Comparison of Laparoscopic and Open Partial Nephrectomy for Tumor in a Solitary Kidney
• Probability of Positive Imaging in Patients with Prostate Cancer After Local Therapy
• Physical Activity and Incident Urinary Incontinence in Middle-Aged Women
• Neoadjuvant Docetaxel and Capecitabine for High Risk Prostate Cancer
• Salvage of Sildenafil Failures With Bremelanotide
• Early Experience With Digital Ureteroscopy
• Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection
• Psychometric Profiles and Hypothalamic-Pituitary-Adrenal Axis Function in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome
• Living Renal Donor Allograft Lithiasis
• Copyright

Back to Article Outline

Long-Term Effects of Lithotripsy on Renal Function and Blood Pressure 

Debate continues concerning the long-term detrimental effects of extracorporeal shock wave lithotripsy (ESWL®). Eassa et al (page 964) from Mansoura, Dakahlia Egypt prospectively studied the records of 100 patients treated with ESWL using either the Dornier MFL 5000 or Dornier Lithotripter S machines. Extensive renal function tests with renal nuclear scintigraphy and blood pressure measurements were conducted before and a mean of 44 months after ESWL monotherapy. Before ESWL 18 patients were hypertensive and at followup 21 patients were hypertensive. Statistically these results do not indicate a long-term (up to 5 years after treatment) effect on blood pressure regardless of which machine is used. These results are reassuring for the short term. Continued data gathering, especially after bilateral ESWL, in patients 20 years after treatment and in diabetic patients, is needed to resolve the question of long-term ESWL effects on renal function.

Back to Article Outline

Impact of Treatment Choice for Localized Prostate Cancer on Response to Phosphodiesterase Inhibitors 

Experts agree that patients often have erectile dysfunction after radiotherapy or radical retropubic prostatectomy. Lee et al (page 1072) from Ann Arbor, Michigan and San Francisco, California used the CaPSURE (Cancer of the Prostate Strategic Urological Research Endeavor) database to examine whether patients treated with radiotherapy or radical prostatectomy monotherapy differed in response to phosphodiesterase (PDE) inhibitors. Data were analyzed from 1,087 men followed for 2 years. Sexual function and sexual bother were assessed using the UCLA Prostate Cancer Index. The authors found that the response rate to PDE inhibitors was roughly the same in both groups. Higher pretreatment sexual function score was a predictor of response to PDE inhibitors. Of interest, there was no significant change in response to PDE inhibitors over time. The inhibitors were found to augment gradual recovery of sexual function after prostatectomy or counteract a decline in sexual function after radiotherapy. Surprisingly, use of bilateral nerve sparing technique did not affect results. Although there are limitations to the CaPSURE database, these results confirm the benefit of posttreatment phosphodiesterase inhibitors and provide further information to help counsel patients regarding erectile function regardless of what therapy they chose.

Back to Article Outline

Comparison of Laparoscopic and Open Partial Nephrectomy for Tumor in a Solitary Kidney 

One might predict that ischemia time might vary between laparoscopic and open partial nephrectomy. An interesting group to examine are patients who undergo partial nephrectomy in a solitary kidney to determine the effect of these approaches on renal function and indirectly the effect on warm ischemia time. Lane et al (page 847) from Cleveland, Ohio compared open nephrectomy with regard to preoperative and postoperative glomerular filtration rates (GFR) using a calculation based on the Modification in Diet in Renal Disease (MDRD) study equation. In multivariate analysis warm ischemia time was 9 minutes longer and the chance of postoperative complications was 2.5 times greater with laparoscopic compared to open partial nephrectomy. A warm ischemia time of more than 20 minutes was associated with poor postoperative GFR. Notwithstanding, the approach itself was not a predictor of postoperative GFR but, rather, the warm ischemia time associated with the approach. Whether laparoscopic open partial nephrectomy is the standard is open to debate. However, these data suggest that close attention to warm ischemia time is important whatever approach is used in an effort to spare nephrons, especially in patients with chronic kidney disease in a solitary kidney.

Back to Article Outline

Probability of Positive Imaging in Patients with Prostate Cancer After Local Therapy 

Knowing when to treat a patient with a biochemical failure after primary therapy for localized prostate cancer is difficult. One strategy may be to ascertain who is at risk for early metastatic disease as noted on imaging studies. In a multi-institutional study Choueiri et al (page 906) reviewed the CaPSURE database and identified 292 patients (66% treated with radical prostatectomy and 34% treated with radiation) with biochemical failure after therapy. Of the patients 31 (11%) had a positive imaging study, and they were further evaluated for predictors of positive imaging indicating metastatic disease. On multivariate analysis age, imaging type, trigger prostate specific antigen (PSA) and PSA doubling time were associated with imaging results. PSA greater than 5 ng/ml and doubling time less than 10 months had a concordance index of 84% for predicting positive imaging. Age greater than 60 years and magnetic resonance imaging versus bone scan or computerized tomography also had a much higher rate of positive results. The appearance of biochemical failure after definitive therapy is the most important predictor of metastatic progression and overall rate of positive imaging. Biochemical failure was low (11%) in this study. The authors conclude that there is no definitive trigger PSA or PSA kinetic parameter that has a high enough predictive value to recommend for or against diagnostic imaging.

Back to Article Outline

Physical Activity and Incident Urinary Incontinence in Middle-Aged Women 

Previous studies suggest that vigorous high impact activity may provoke stress urinary incontinence (UI). Obesity is another positive predictor or risk factor. Townsend et al (page 1012) from Boston, Massachusetts examined the Nurses’ Health Study and found that moderate physical activity was associated with a decrease in UI based in part on patient self-reporting. Moderate physical activity was an independent predictor inversely related to urine loss. Body mass index was a stronger risk factor for frequent UI in middle-aged women. The authors conclude that multiple mechanisms are involved in the association between physical activity and UI but not body weight alone. It would seem prudent to advise women to maintain an ideal body weight and perform moderate exercise for a variety of reasons including urinary control.

Back to Article Outline

Neoadjuvant Docetaxel and Capecitabine for High Risk Prostate Cancer 

Patients with high risk prostate cancer, defined as clinical stage T3, PSA greater than 15 ng/dl or Gleason score greater than or equal to 8, have a 5-year biochemical failure rate of 50% or greater. Adjuvant androgen deprivation therapy has been the only approach tried that has affected survival in select patients. Friedman et al (page 911) from Ann Arbor, Michigan studied 15 high risk patients after radical prostatectomy enrolled in a phase II study of neoadjuvant capecitabine and docetaxel. A unique aspect of the study was immunohistochemistry for thymidine phosphorylase and survivin before and after chemotherapy to determine if docetaxel induced decreases in survivin and increases in thymidine phosphorylase which would help convert capecitabine to an active drug. Of the 15 patients 6 (40%) experienced side effects including diarrhea and the hand-foot syndrome. Overall, the results were not sufficient to warrant an expansion of the trial of neoadjuvant docetaxel and capecitabine. Nonetheless, neoadjuvant approaches such as these may hold promise for reducing failure rates in high risk patients with prostate cancer.

Back to Article Outline

Salvage of Sildenafil Failures With Bremelanotide 

The search continues for pharmacological agents to combat sexual dysfunction, especially after failure of phosphodiesterase type 5 inhibitors. Safarinejad and Hosseini (page 1066) from Tehran, Islamic Republic of Iran enrolled 342 men who failed to respond to sildenafil in a placebo controlled trial of a melanocortin type 4 receptor agonist (melanocyte), bremelanotide, administered intranasally. The primary outcome measure was assessment of questions 3 and 4 on the International Index of Erectile Function. Of the bremelanotide group 33% reported improvement in sexual function compared to 8% of the placebo group. Of interest, nearly 78% of men characterized as having psychogenic erectile dysfunction demonstrated a response. The side effects included nausea in 3% of cases and flushing in 10%. Although the effects with bremelanotide were modest, reports such as this suggest a future role for this agent, especially as an adjunct to sex therapy in men with psychogenic erectile dysfunction.

Back to Article Outline

Early Experience With Digital Ureteroscopy 

One merely has to compare analogue and digital television to appreciate the incredible imaging obtained with digital technology. Humphreys et al (page 970) from Indianapolis, Indiana report on 8 patients in whom a new digital ureteroscope was used to image renal calculi. Not surprisingly, superior images were obtained compared to 3 different analogue systems. While image enhancement was evaluated, the real potential of this technology will be to allow miniaturization of future endoscopic devices. The distal tip objective is a complementary metal oxide semiconductor sensor coupled to a prism. The light source consists of 2 light emitting diodes at the objective tip automatically adjusting for maximal image resolution. Continued advances such as this will push forward our ability to manage urological disorders using extremely small devices.

Back to Article Outline

Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection 

Dhar et al (page 873) from Bern Switzerland and Cleveland, Ohio evaluated recurrence and survival of patients with urothelial bladder cancer who had undergone either limited or extended pelvic lymph node dissection (PLND). The 5-year recurrence-free survival rate was 7% for limited and 35% for extended PLND. The 5-year recurrence-free survival for patients with 2 disease negative nodes was 63% for limited and 71% for extended PLND. Finally, for T3 disease and negative lymph nodes survival rates were 23% and 57% in the limited and extended PLND groups, respectively. These data suggest that limited PLND is associated with suboptimal staging, poorer outcome and a higher rate of local progression. This study adds to mounting evidence that the more lymph nodes removed during radical cystectomy the better the outcome.

Back to Article Outline

Psychometric Profiles and Hypothalamic-Pituitary-Adrenal Axis Function in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome 

Anderson et al (page 956) from Stanford, California report that men with chronic prostatitis/chronic pelvic pain syndrome scored significantly higher on all psychosocial variables including anxiety and had evidence of dysfunctional hypothalamic-pituitary-adrenal axis function in augmented awakening cortisol response. Of interest, hypothalamic-pituitary-adrenal system controllers such as distress were elevated in victims of childhood abuse. This finding combined with data from women suggests a common pathophysiology in character traits in individuals with chronic pelvic pain. The hope is that one day these observations can result in more targeted therapy to the central stress system to reduce stress and anxiety as well as relieve pain.

Back to Article Outline

Living Renal Donor Allograft Lithiasis 

The shortage of renal donors combined with the use of sensitive computerized tomography of potential donors has resulted in increased detection of renal calculi in donors, raising the issue of the use of these donors for renal transplantation. Guidelines have been published addressing this issue. Strang et al (page 832) from Birmingham, Alabama provide a nice review of current thought on transplantation using these donors. Obvious risks include those to the donor due to stone disease and the recipient due to allograft failure caused by nephrolithiasis or obstruction. In general, patients with cystine/struvite stones which have a high recurrence rate, enteric hyperoxaluria, distal renal tubular acidosis, sarcoidosis, inflammatory bowel disease or other conditions that cause nephrocalcinosis should not donate kidneys. However, multi-section computerized tomography of renal donors has changed nephrolithiasis from an absolute to a relative contraindication. The authors recommend careful evaluation of asymptomatic potential donors with a single previous episode of nephrolithiasis. In general, the older the donor and the smaller the stone, the more likely these patients will be allowed to donate. The authors stress the importance of educating donors about future risk of nephrolithiasis. This review should be read by anyone advising renal allograft donors, or performing donor nephrectomies or renal transplants.