This Month in Clinical Urology

Article Outline

• Single Stage Reconstruction of Complex Anterior Urethral Stricture Disease
• Long-Term Effects of Extracorporeal Shock Wave Lithotripsy on Renal Function
• Correlation of Circulating Tumor Cells and Prostate Cancer
• Oncological Evaluation of Prostate Sparing Cystectomy
• Tumor Characteristics of Carriers and Noncarriers of deCODE 8q24 Prostate Cancer Susceptibility Alleles
• Interactive Spaced Education Versus Web-Based Modules for Teaching Urology to Medical Students
• Effects of 5α-Reductase Inhibition With Dutasteride and Finasteride in Healthy Young Men
• Urinary Nerve Growth Factor Could be a Potential Biomarker for Diagnosis of Overactive Bladder
• Evoked Cavernous Activity
• Copyright

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Single Stage Reconstruction of Complex Anterior Urethral Stricture Disease 

The management of long strictures distal to the bulbous urethra remains challenging even for experienced surgeons. The circular fasciocutaneous flap (also referred to as the Dartos flap) is 1 option. There have been few studies on long-term (greater than 5 years) outcomes for the management of urethral strictures. Whitson et al (page 2259) from San Francisco, California report results for 124 patients with stricture disease with up to 10 years of followup (median 7.3 years). Although stricture-free rates slowly declined during the 10 years, 79% of 33 men followed for 10 years or more remained free of stricture. The fasciocutaneous flap technique appears to be durable with respectable results. Of the remaining patients 26 were lost to followup and 6 died. Perhaps if these patients had been followed the failure rate might have been somewhat higher.

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Long-Term Effects of Extracorporeal Shock Wave Lithotripsy on Renal Function 

El-Assmy et al (page 2229) from Mansoura, Egypt studied the effects of extracorporeal shock wave lithotripsy (ESWL®) on renal function in 156 patients with a single kidney. Mean followup was 3.8 years (range 1 to 16), and 108 patients were followed for more than 1 year. ESWL was performed with a MFL 500 Dornier lithotriptor. Renal function was measured using the Cockroft-Gault formula for glomerular filtration rate. There were no statistically significant changes in serum creatinine and calculated glomerular filtration rate, leading the authors conclude that ESWL has no adverse effect on renal function. Although somewhat reassuring, these results cannot be extrapolated to other lithotriptors or patient populations. One must also worry about a slight decline in renal function reported in some patients with a solitary kidney independent of ESWL.

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Correlation of Circulating Tumor Cells and Prostate Cancer 

Detection of circulating tumor cells (CTCs) by the CellSearch^™ system has been used to stage breast cancer and more recently prostate cancer. Davis et al (page 2187) from Houston, Texas used this technique to ascertain whether CTCs correlate with prognosis of clinically localized prostate cancer. This methodology involves use of iron particles coated with epithelial cell specific antibody. The authors found that there were no more CTCs in patients with prostate cancer (20%) than in controls (20%) with an increased prostate specific antigen but no tumor on biopsy. CTCs did not correlate with tumor volume, pathological stage or Gleason score. Of the patients with prostate cancer and CTCs at baseline 90% had no CTCs after radical prostatectomy. The authors conclude that CellSearch CTC detection does not appear to be useful in the setting of localized prostate cancer.

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Oncological Evaluation of Prostate Sparing Cystectomy 

Rozet et al (page 2170) from Paris, France report on 117 patients with a minimum followup of 2 years after prostate sparing cystectomy. Local recurrence and distant recurrence of bladder cancer developed in 4.7% and 34% of the patients, respectively. The overall survival at 5 years was 67%. The authors compare their results to stage and grade matched published results. Compared by stage, the results indicate that prostate sparing cystectomy seems to be just as effective as cystoprostatectomy in select patients undergoing a protocol of preoperative transurethral resection of the prostate and/or intraoperative frozen sections to exclude residual tumor or prostate cancer. Of note, there was no control group and the authors admit that patients with under staged disease preoperatively would not have been candidates (pT4). In addition, an extended pelvic lymph node dissection was not performed in many patients. Nonetheless, the authors remain optimistic about using this technique to spare the neurovascular bundle and prostate apex, thereby potentially enhancing continence and potency rates in patients undergoing cystectomy for bladder cancer.

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Tumor Characteristics of Carriers and Noncarriers of deCODE 8q24 Prostate Cancer Susceptibility Alleles 

Helfand et al (page 2197) from Chicago, Illinois continue their study of genetic markers involving a region on chromosome 8 known as 8q24 for identifying patients at risk for and prognosis of prostate cancer. They prospectively evaluated 551 men treated with radical prostatectomy (535) or radiation therapy (16) for prostate cancer. Of these men 32.1% were carriers of at least a single 8q24 CaP risk allele, 13.97% were carriers of the -8 allele of the microsatellite marker DG8S737, 23.2% were carriers of the A allele of the single nucleotide polymorphism (SNP) rs1447295 and 11.1% were carriers of the A allele of SNP rs16901979. Patients with the -8 allele or A allele of SNP rs16901979 were more likely to have high grade disease, as were those with multiple alleles. These results provide support for the association of the 8q24 alleles with histologically and pathologically more aggressive prostate cancer. Of interest, these alleles were a higher predictor of prostate cancer than a positive family history.

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Interactive Spaced Education Versus Web-Based Modules for Teaching Urology to Medical Students 

There are few controlled trials using an internet based teaching modality for surgical education. Kerfoot (page 2351) from West Roxbury, Massachusetts presents a carefully performed study in which students were subjected either to interactive spaced education or a web based case module method of teaching core topics in urology. He noted that the web based and interactive spaced learning resulted in higher test scores. It appears that interactive spaced education resulted in higher test scores than web based training but the difference did not reach statistical significance. Both modalities were deemed effective for teaching. The author plans to examine the degree to which interactive spaced education is effective as a method of continuing medical education among urologists and urology residents.

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Effects of 5α-Reductase Inhibition With Dutasteride and Finasteride in Healthy Young Men 

Because androgens affect bones, lipids, hematopoiesis, and prostate and sexual function, Amory et al (page 2333) from Seattle, Washington conducted a randomized, double-blind, placebo controlled trial in 99 men randomly assigned to receive finasteride, dutasteride or placebo for a year to ascertain whether inhibition of 5α-reductase influences these parameters. The parameters were measured at baseline, after 1 year of treatment and 6 months following discontinuation of treatment. Patients did not have any significant reduction in bone mineral density or alteration in serum lipoproteins 1 year after treatment. However, there was the expected decrease in prostate specific antigen. Sexual function assessed using a validated Likert scale revealed that 5α-reductase inhibitors resulted in a slight but not statistically significant subjective reduction in sex drive, erectile function, ejaculatory function, problems with sexual activity and overall satisfaction with sexual activity. The authors conclude that administration of 5α-reductase inhibitors had no effect on a variety of sexual parameters known to be impacted by androgens. They also predict that chronic inhibition of 5α-reductase is unlikely to influence the development of osteoporosis or the risk of cardiovascular disease.

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Urinary Nerve Growth Factor Could be a Potential Biomarker for Diagnosis of Overactive Bladder 

A variety of experimental animal and clinical studies have demonstrated that nerve growth factor (NGF) level increases in bladder tissue and urine of subjects with lower urinary tract symptoms including male and female pelvic pain disorders and bladder outlet obstruction. This prompted Liu and Kuo (page 2270) from Taiwan, Province of China to evaluate the usefulness of urinary NGF as a diagnostic test for detrusor overactivity. The authors found that mean urinary NGF was significantly higher in patients with overactive bladder who were incontinent compared to those with overactive bladder who were dry. However, when the NGF levels were normalized to the concentration of creatinine to greater than 0.05%, sensitivity was 67.9% and specificity was 93.8% in all patients with overactive bladder. These findings offer some insight into the pathogenesis of urge incontinence in patients with neurogenic bladder.

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Evoked Cavernous Activity 

Aside from a detailed history it is often difficult to ascertain whether erectile dysfunction (ED) arises from alterations in cavernous smooth muscle, autonomic or somatic nerves, or the vasculature. Yang et al (page 2312) from Seattle, Washington subjected 37 sexually active men to evoked cavernous activity and compared the results to sympathetic skin response, which is the standard test for autonomic neural activity. They found that evoked cavernous activity was similar to sympathetic skin responses, suggesting that this test may be useful to assess autonomic nerves supplying the penis. These normal values can be compared to those derived in men with erectile dysfunction to ascertain if evoked cavernous activity could be a useful diagnostic test.