This Month in Clinical Urology

Article Outline

• Is Chronic Inflammation Associated More With Benign Prostatic Hyperplasia or Cancer?
• PCA3 Molecular Urine Assay Correlates With Prostate Cancer Tumor Volume
• Comprehensive Prospective Comparative Analysis of Outcomes between Open and Laparoscopic Radical Prostatectomy
• Laparoscopic Versus Open Approach for Ureterolysis in Patients With Retroperitoneal Fibrosis
• Implantation of an Adjustable Continence Therapy System Using Local Anesthesia
• Long-Term Durability and Functional Outcomes of Artificial Urinary Sphincters
• Radiographic Parameters Predictive of Shock Wave Lithotripsy Success
• Oral Ketoconazole for Prevention of Postoperative Penile Erection
• Birth Weight, Abdominal Obesity and the Risk of Lower Urinary Tract Symptoms
• Copyright

Back to Article Outline

Is Chronic Inflammation Associated More With Benign Prostatic Hyperplasia or Cancer? 

Chronic inflammation has been implicated in the pathogenesis of benign prostatic hyperplasia (BPH) and prostate cancer. However, many of the studies are biased toward clinic populations and patients with abnormal prostate specific antigen (PSA) or are based on random biopsies. Delongchamps et al (page 1736) from Syracuse, New York report on a prospective collection of autopsied glands for acute and chronic inflammation with and without BPH, and with and without prostate cancer. They found no significant difference in the degree of inflammation in glands with BPH alone, prostate cancer alone, BPH and cancer, and glands with neither BPH nor cancer. Chronic inflammation was significantly more prevalent in glands with BPH (75%) compared to glands without BPH (50%). However, the prevalence of chronic inflammation was not associated with that of prostate cancer. Comparatively, of the glands with and without evidence of cancer 55% and 58%, respectively, were involved with chronic inflammation. These findings confirm the ubiquitous nature of chronic inflammation in prostate glands.

Back to Article Outline

PCA3 Molecular Urine Assay Correlates With Prostate Cancer Tumor Volume 

PCA3 is a molecular marker synthesized by prostate cancer cells. Recent studies have shown that PCA3 urine assay has promise in improving the diagnostic accuracy of prostate cancer, especially in men with equivocal PSA values. Nakanishi et al (page 1804) from Houston, Texas and Atlanta, Georgia hypothesized that PCA3 score would correlate with prostate cancer volume. The PCA3 score was defined as the ratio of PCA3 mRNA/PSA mRNA × 10³. On multiple regression analysis transrectal ultrasound prostate volume, biopsy Gleason score, percent positive cores on biopsy, log PSA and log PCA3 score were independent predictors of lower volume cancer (less than 5 cc) in prostatectomy specimens. Among these variables log PCA3 score was the best predictor based on ROC curve analysis for low volume cancer defined by total tumor volume. The authors suggest that the urine PCA3 score may help physicians select patients suitable for active surveillance.

Back to Article Outline

Comprehensive Prospective Comparative Analysis of Outcomes between Open and Laparoscopic Radical Prostatectomy 

Recent enthusiasm for the laparoscopic approach to radical prostatectomy has not been based on prospective randomized trials with comparison to open retropubic prostatectomy. Touijer et al (page 1811) from New York, New York suggest that surgeon experience may be a more crucial variable than surgical technique, making randomized trials problematic. The authors compared surgeon experiences with high volume open versus laparoscopic prostatectomy. Positive surgical margin rate, potency and biochemical failure were similar in both groups. Laparoscopic prostatectomy was associated with significantly less blood loss, lower transfusion rates and a shorter length of hospital stay. However, the reoperation rate was somewhat higher with laparoscopic versus retropubic prostatectomy. Also, the return of continence was delayed after the laparoscopic (12 months) versus the open procedure. This latter result was attributed to more extensive dissection at the prostatic apex to obtain a lower positive margin rate. These results would seem to confirm the efficacy and safety of the laparoscopic approach versus open prostatectomy.

Back to Article Outline

Laparoscopic Versus Open Approach for Ureterolysis in Patients With Retroperitoneal Fibrosis 

Srinivasan et al (page 1875) from New York, New York retrospectively examined laparoscopic and open ureterolysis in patients with primary and secondary retroperitoneal fibrosis. Two surgeons performed all of the procedures in the study groups. The choice of open versus laparoscopic surgery was based on surgeon preference rather than randomization. In this large series the authors found that, similar to previous reports, laparoscopic ureterolysis is a safe and effective technique. Most patients in this study had primary idiopathic retroperitoneal fibrosis and were treated with the laparoscopic procedure, which was associated with a shorter hospital stay and lower transfusion rate. Relief of obstruction was similar between the open (91%) and laparoscopic (94.3%) groups. Conversion from the laparoscopic to the open procedure was necessary in 17.6% of the cases.

Back to Article Outline

Implantation of an Adjustable Continence Therapy System Using Local Anesthesia 

Gregori et al (page 1902) from Milan, Italy describe their technique using local anesthesia to implant the new minimally invasive device ProACT™ for the management of stress incontinence following radical prostatectomy. Although efficacy was not the primary outcome in the study, these authors report that after allowing for adjustments, 63.6% of patients were dry (no pad usage) and 36.4% were improved. In addition to the ability to adjust compression postoperatively, an advantage of this new technique over male slings and the artificial urinary sphincter may be the ease of placement as well as the ability to place the device using local anesthesia. Obviously, short of prospective randomized trials comparing male slings, artificial sphincter and the ProACT system, surgeons will continue to debate the respective merits of each technique.

Back to Article Outline

Long-Term Durability and Functional Outcomes of Artificial Urinary Sphincters 

In one of the largest and longest studies of artificial urinary sphincter durability and outcome Kim et al (page 1912) from Ann Arbor, Michigan followed 124 male patients for a median of 6.8 years. Sphincters were implanted between 1996 and 2006. The overall complication rate was 37% with the most common cause of failure being mechanical followed by erosion and infection. Of the patients 9.5% required surgical removal for infection or erosion. No daily pad use was reported by 27.1% of the patients and 52% reported using 1 pad a day. The severity of incontinence and daily pad usage were stable at 8 years. Based on Kaplan-Meier plot of long-term durability, it would seem that mechanical failure peaked after 36 months. This study presents candid information when advising patients.

Back to Article Outline

Radiographic Parameters Predictive of Shock Wave Lithotripsy Success 

It is well-known that Hounsfield units as measured by computerized tomography (CT) provide insight in renal stone composition which can have predictive value of shock wave lithotripsy (SWL) success independent of calculus size and position. Kacker et al (page 1866) from Chicago, Illinois studied the relationship between SWL success and radiographic measures on noncontrast CT in an effort to improve estimates of fragmentation. The patients were considered stone-free at 3 months if there was no evidence of residual stone fragments on CT or excretory urography with tomograms. Stones with an average density less than 500 HU had at least 3.28 times the odds of successful fragmentation compared to stones with average attenuation greater than 500 HU. Average rather than maximal stone attenuation was the superior predictor of success. The authors warn that this method may not be practical for every patient, and may be most useful for high and low HU extremes or patients with stones in positions with poor SWL success rates.

Back to Article Outline

Oral Ketoconazole for Prevention of Postoperative Penile Erection 

Previous retrospective analyses have suggested that high dose oral ketoconazole by virtue of androgen suppression may be useful for preventing erections following penile surgery. DeCastro et al (page 1930) from Tacoma, Washington performed a prospective randomized trial which contrasted with previous reports based on retrospective analysis. Of their patients 83% in the placebo group experienced erections compared to 81% in the ketoconazole (400 mg 3 times daily) group. This study confirms that before incorporating various drug treatments into urological practice, clinicians should not accept anything less than prospective randomized trials, the results of which often differ from anecdotal reports.

Back to Article Outline

Birth Weight, Abdominal Obesity and the Risk of Lower Urinary Tract Symptoms 

An increasing number of reports suggest that obesity is associated with lower urinary tract symptoms attributed to BPH. Laven et al (page 1891) from Solna, Sweden examined the Cohort of Swedish Men database to determine whether obesity per se based on body mass index or abdominal obesity inferred from a waist-to-height index was predictive of lower urinary tract symptoms as documented by International Prostate Symptom Score. Abdominal obesity but not body mass index was predictive of lower urinary tract symptoms. In addition, the authors report that low birth weight, which has been associated with abdominal obesity, was also predictive of lower urinary tract symptoms. However, the data on low birth weight were based on patient recall. It is intriguing that low birth weight serves as a marker for susceptibility to adult abdominal obesity and hyperinsulinemia, both of which may increase sympathetic nerve activity and induce lower urinary tract symptoms.