This Month in Adult Urology

Article Outline

• Tadalafil for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia
• Bilateral Nerve Sparing Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer
• Daily Cranberry Juice for Prevention of Asymptomatic Bacteriuria During Pregnancy
• What Percentage of Patients With Newly Diagnosed Carcinoma of the Prostate are Candidates for Surveillance?
• Immunomagnetic Quantification of Circulating Tumor Cells as a Prognostic Factor of Androgen Deprivation Therapy
• Testosterone Recovery After Prolonged Androgen Suppression in Patients With Prostate Cancer
• Evaluation of Serum and Urine MRP-14 as a Marker for Prostate Cancer Detection
• Effect of Statin on Bladder Transitional Cell Carcinoma
• Mental Health of Patients With Chronic Pain Syndromes
• Predicting Prostate Cancer Risk Using PCA3
• Prostate Screening in Patients With 46,XY Disorders of Sex Development
• Copyright

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Tadalafil for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia 

Recent data suggest that phosphodiesterase type 5 (PDE5) inhibitors such as tadalafil may help alleviate lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). In a landmark study by Roehrborn et al (page 1228) from Dallas, Texas 2.5 to 20 mg tadalafil once daily was given to men with increased International Prostate Symptom Score (I-PSS). Daily tadalafil significantly reduced I-PSS anywhere from 3.9 to 5.2 points compared to placebo (−2.3) at 4, 8 and 12 weeks. In addition, improvements occurred in the obstructive and irritative I-PSS, demonstrating that once daily tadalafil has beneficial results for LUTS attributed to BPH. The magnitude of benefit is similar to other classes of drugs used to treat BPH. Moreover, the International Index of Erectile Function also improved. Interestingly, the increase in maximum urinary flow rates was not significantly superior with tadalafil vs placebo. Thus, improvements in LUTS after tadalafil may be independent of reduced outlet resistance. With Food and Drug Administration approval of 5 mg tadalafil daily, clinicians may now have an agent that treats coexisting LUTS and erectile dysfunction.

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Bilateral Nerve Sparing Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer 

Not so long ago it was heresy to suggest that laparoscopic retroperitoneal lymph node dissection (L-RPLND) for testicular cancer should even be considered because of the potential for residual disease. Steiner et al (page 1348) from Innsbruck, Austria present a study of 42 patients with stage I (21), stage IIA marker negative (2) and post-chemotherapy stage IIA (19) disease who underwent transperitoneal bilateral L-RPLND. Mean operating time was 323 minutes. Teratoma was found in the lymphatic tissue of 4 of the 19 post-chemotherapy cases. No retroperitoneal recurrence was noted. Pulmonary metastases developed 9 months after surgery in 1 patient with negative retroperitoneal histology which was successfully treated. All patients are currently disease-free with a mean followup of 17.2 months. Antegrade ejaculation was preserved in 36 patients. The authors conclude that bilateral nerve sparing L-RPLND is feasible with low morbidity if performed by experienced surgeons. If these results are confirmed by others, the approach to managing lymph nodes in select (eg marker negative) men with testis cancer may shift from open to laparoscopic surgery.

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Daily Cranberry Juice for Prevention of Asymptomatic Bacteriuria During Pregnancy 

Previous analyses have suggested that cranberry juice or tablets may be of benefit in preventing urinary tract infections (UTIs) in women. However, this has not been rigorously examined in pregnant women with asymptomatic or symptomatic urinary tract infections. Wing et al (page 1367) from Irvine, California provide a prospective, randomized, placebo controlled trial of cranberry juice for the prevention of asymptomatic bacteriuria, UTIs, cystitis and pyelonephritis. There were 63 subjects in the control group, 58 subjects received cranberry 3 times a day, while 67 subjects received cranberry juice once at breakfast, and placebo at lunch and dinner. There was a 57% reduction in asymptomatic bacteriuria and a 41% reduction in all UTIs in the multiple daily dose group. However, this study was not sufficiently powered to reach statistical significance. A total of 73 subjects withdrew from the study because of gastrointestinal upset suggesting the amount of juice needed for optimal benefit if any may be poorly tolerated. These data hint at a possible protective effect of cranberry juice for asymptomatic bacteriuria and UTI. The controversy persists and further studies are needed.

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What Percentage of Patients With Newly Diagnosed Carcinoma of the Prostate are Candidates for Surveillance? 

An observational study was conducted by Barocas et al (page 1330) of 1,886 men with localized prostate cancer between 1999 and 2004 as part of the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) database to determine the percentage of men meeting Epstein surveillance criteria (defined as prostate specific antigen [PSA] less than 10, clinical T1 T2a, PSA density less than 0.15, fewer than a third of positive biopsy cores, and absence of Gleason pattern 4 and 5 on biopsy) and the percentage selecting surveillance stratified by risk group. Up to 16.4% of men who underwent treatment met criteria for the low risk category but only 9% of the men in this group actually chose surveillance. On multivariate analysis older age was the only demographic predictor of surveillance. The authors conclude that surveillance is under utilized in the management of low risk prostate cancer. Only a small subset of eligible patients selected surveillance.

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Immunomagnetic Quantification of Circulating Tumor Cells as a Prognostic Factor of Androgen Deprivation Therapy 

Circulating tumor cells have been used to provide insight into the diagnosis, therapeutic options or treatment failure in a variety of tumors including prostate cancer. Okegawa et al (page 1342) from Tokyo, Japan assessed whether circulating tumor cells can predict PSA failure before endocrine therapy and compared their prognostic capacity with other clinical factors. They initially spiked prostate cancer cell lines and looked at recovery rates based on the automated CellSearch system (Veridex, Warren, New Jersey). The recovery rates were 69% from PC3 cells vs 95% from LNCaP cell lines and 89% from DU145 cell lines. In a second set of experiments the authors followed 82 men with known metastatic prostate cancer at initial presentation using the CellSearch technique. Circulating tumor cells less than 5 per 7.5 ml of blood were associated with a longer duration of response (32 months) to androgen deprivation therapy compared to greater than 5 cells (17 months). The authors conclude that looking for circulating tumor cells may predict relapse in hormonally naïve patients. If the number of circulating tumor cells is less than 5 a longer period of response can be expected. The authors indicate that this technique may be better than PSA nadir at predicting response to therapy.

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Testosterone Recovery After Prolonged Androgen Suppression in Patients With Prostate Cancer 

A subset of patients undergoing testosterone ablation recover testosterone to baseline levels. In a study of 141 patients whose testosterone levels were reduced to castrate levels for testosterone recovery (121 after 2 years and 20 after a median of 16 months) Yoon et al (page 1438) from Toronto, Ontario, Canada performed a followup evaluation at 36 months. Of the patients 93.2% and 71.5% had recovery to supracastrate or baseline/normal testosterone levels, respectively. Median time was 12.7 months to recovery of supracastrate levels and 22.3 months to recovery of baseline/normal levels. Younger age and shorter duration of suppression were prognostic factors for recovery to baseline testosterone levels. These data are worth remembering when patients are considered for intermittent androgen ablation and can be used to assess which ones are likely to achieve pre-suppression levels of testosterone after ablation.

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Evaluation of Serum and Urine MRP-14 as a Marker for Prostate Cancer Detection 

Previous small pilot studies have suggested that myeloid related protein 14 (MRP-14) in serum and urine may be predictive of aggressive prostate cancer. In a population based, prospective study between July 2000 and December 2002 Müller et al (page 1309) from Heidelberg, Germany selected 2 cohorts of patients with prostate cancer. The first group consisted of 32 cases of incidental prostate cancer diagnosed within a 2-year followup and the second consisted of 24 cases of prostate cancer for which a pretreatment serum sample was available. Also included in the study was a control group of 74 patients with no history of cancer. This nested case controlled study revealed that serum and urine MRP-14 at 2 years of followup was not helpful in diagnosing prostate cancer based on ROC curve analysis. In fact, MRP-14 performed worse than PSA and did not discriminate between cases and controls. Although the authors raise concern about limitations with their case control design and handling of frozen specimens, the initial enthusiasm for this type of test appears to be premature.

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Effect of Statin on Bladder Transitional Cell Carcinoma 

Statins may modulate immune responses. Thus, Berglund et al (page 1297) from New York, New York examined whether statin use during bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder influenced outcomes. In this retrospective review 245 (26%) patients were given a statin before BCG therapy and 707 were not. Median time to recurrence was similar between the groups. On multivariate analysis statin use was not significantly associated with recurrence or progression to surgery. Thus, the use of statins to manage hyperlipidemia appears to be safe in the context of BCG therapy for bladder cancer.

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Mental Health of Patients With Chronic Pain Syndromes 

It would seem logical that patients with chronic pain syndromes may suffer from a certain amount of mental health issues. Using a patient health questionnaire to assess mental health disorders, including a 9-item depression module and a 5-item anxiety module, Clemens et al (page 1378) from Ann Arbor, Michigan reported that 13% of men with chronic prostatitis met the criteria for a mental health diagnosis vs 4% of controls. Of women with interstitial cystitis or painful bladder syndrome 23% had evidence of a mental health disorder vs 3% of controls. Disease status and income were the only 2 variables predictive of a mental health diagnosis, with an annual household income of greater than $50,000 demonstrating lower chances of a mental health diagnosis. Medications for anxiety, stress or depression were taken by at least 18% of chronic prostatitis patients and at least 37% of interstitial cystitis patients, compared to 7% of male controls and 13% of female controls. Depression and panic disorder were significantly more common in men and women with chronic pelvic pain than controls, although many of the patients were on medications, suggesting that mental health disorders may be more difficult to treat in these patients.

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Predicting Prostate Cancer Risk Using PCA3 

Urinary PCA3 is being increasingly mentioned as a possible new test to predict prostate cancer and avoid unnecessary prostate biopsies. A Prostate Cancer Prevention Trial (PCPT) risk calculator which combines PSA, digital rectal examination, family and biopsy history, age and race has been validated for determining the risk of prostate cancer. Ankerst et al (page 1303) from San Antonio, Texas incorporated urinary PCA3 into this calculator and examined the area under the receiver operating characteristic curve for sensitivity and specificity. PSA was not significantly different from PCA3, and the sensitivities of posterior risks were higher than PCA3, PSA and other elements of the PCPT risks. The authors conclude that PCA3 does improve the diagnostic accuracy of the PCPT risk calculator. While questions can be raised whether this risk model can be generalized to other populations, the authors conclude that incorporating PCA3 into a group of other factors did not increase the area under the curve compared to PCA3 alone for the entire group. However, when applied to individual patients, incorporation of PCA3 into the PCPT risk calculator refined the evaluation, with a low PCA3 value translating to a decreased risk and a high value translating to an increased risk.

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Prostate Screening in Patients With 46,XY Disorders of Sex Development 

The role of prostate screening of patients with 46,XY disorders of sexual development (DSD) is unknown. Because an index case of prostate cancer in this population has not been reported, questions have been asked whether the prostate in cases of DSD manufactures PSA and if screening is of value. Salmasi et al (page 1422) from Baltimore, Maryland obtained PSA values in 26 patients with micropenis, complete and partial androgen insensitivity syndrome, and mixed gonadal dysgenesis. All patients had a small palpable prostate gland with no abnormalities on DRE. Measurable PSA levels in intersex patients were comparable to those of age and race matched controls. The authors recommend that patients with 46,XY DSD be screened for prostate cancer similar to men without DSD. Because these men have similar PSA levels they may have similar risk factors or possibly higher risk factors due to androgen receptor abnormalities or exogenous androgen therapy.