Locally Recurrent Prostate Cancer After Initial Radiation Therapy
An estimated 50,000 men a year in the United States will have prostate specific antigen (PSA) recurrence after either initial radical prostatectomy or radiation therapy. If no further treatment is given, nearly three-quarters of these men will have clinical evidence of recurrent prostate cancer within 5 years of biochemical failure. Many reports document the efficacy and potential complications of local salvage therapies, including salvage radical prostatectomy vs cryotherapy. Pisters et al (page 517) accumulated a series of patients from several institutions who underwent either salvage prostatectomy or cryosurgery. Their retrospective review revealed that salvage prostatectomy resulted in superior biochemical disease-free survival by 2 separate definitions and superior overall survival. However, there was no difference in disease specific survival at 5 years. After adjusting for post-radiation therapy biopsy Gleason score and pre-salvage treatment serum PSA levels, salvage radical prostatectomy still remained superior to salvage cryotherapy. Thus, the authors conclude that patients with recurrent prostate cancer should consider salvage radical prostatectomy because of its superior biochemical disease-free and overall survival. It should be noted that participation in the study was limited to patients who received radiation therapy alone, had pre-salvage PSA levels of less than 10 ng/ml and had a post-radiation therapy biopsy proven Gleason score of less than 8. Patients with large volume clinical stage T3 or T4 disease and nodal or bone metastasis were also excluded from study. Morbidity of each approach was not reported.
Microvascular Arterial Bypass Surgery
Although penile microarterial bypass surgery has been performed since 1972, limited data are available on this procedure using validated outcomes in a large patient series. Munarriz et al (page 643) from Boston, Massachusetts report long-term outcome data using validated instruments in 71 men younger than 55 years who underwent microarterial bypass surgery using the technique of end-to-end anastomosis of the inferior epigastric artery to the dorsal artery. Evaluation of penile rigidity with and without phosphodiesterase inhibitors was performed before and after surgery. Mean preoperative and postoperative sexual distress scale scores and depression scores were tallied against treatment satisfaction. Patients who had pure cavernous artery insufficiency and those with vascular risk factors or psychiatric dysfunction were excluded from analysis. In these carefully selected patients the results showed statistically significant improvements in outcomes with a low rate of side effects and a high level of patient satisfaction.
Association of Lower Urinary Tract Symptoms and the Metabolic Syndrome
Lower urinary tract symptoms (LUTS) have been associated with components of the metabolic syndrome (MetS) such as hypertension, increased fasting blood glucose, erectile dysfunction and lifestyle factors including physical inactivity, alcohol consumption and smoking. Kupelian et al (page 616) used the Boston Area Community Health Survey instrument to examine the risk of men having 3 or more components of MetS as a function of the presence and severity of LUTS. Specifically, they looked at LUTS as defined by the American Urological Association Symptom Index (AUA-SI) and MetS, and the relationship between individual symptoms comprising the AUA-SI and MetS. MetS was defined as 3 or more of waist circumference greater than 102 cm; systolic blood pressure 130 mm Hg or greater, diasolic blood pressure 85 mm Hg or greater, or antihypertensive medication use; high density lipoprotein cholesterol less than 40 mg/dl or lipid mediation use; self-reported type 2 diabetes or increased blood sugar, or diabetes medication use; and triglycerides greater than 150 mg/dl. The overall presence of MetS was 29% and prevalence was lowest in men reporting no or only 1 symptom. Increased odds of MetS were seen in men with mild to moderate LUTS (AUA-SI 2 to 3 or 5) compared to men with an AUA-SI of 0 or 1. These correlations were also noted primarily among men younger than 60 years vs those 65 years old or older. This study provides further evidence for an association between MetS and LUTS, and suggests possible common factors.
Prostatic Abscess Due to Burkholderia pseudomallei
Prostatic abscesses are relatively rare. Morse et al (page 542) from the Northern Territory of Australia report the largest series to date due to infection from Burkholderia pseudomallei, the causative agent of melioidosis, which is common in soil and water in southeast Asia and northern Australia. The prostatic abscess was identified by computerized tomography, and of 357 male patients with melioidosis 77 had 81 prostatic abscesses. Of these 77 men 74 presented with primary prostatic disease, and prostatic abscess was the major clinical presentation in 55 (68%). All patients were treated with antibiotics and 57 of the 81 abscesses were drained. The most common urological findings on examination were prostatic enlargement and tenderness, and more than half of the men were in urinary retention at presentation. For the few urologists in Western countries who treat prostatic abscesses in sufficient numbers to gain much experience, the authors provide useful guidelines for its detection and management.
Residual Pathological Stage at Radical Cystectomy Impacts Outcomes
In a multi-institutional study Isbarn et al (page 459) evaluated the impact on recurrence and cancer specific mortality rates of down staging between transurethral resection of bladder tumor and radical cystectomy. The study included patients with clinical stage T2 at transurethral resection and pathological stage less than T2 at radical cystectomy without clinical or pathological evidence of lymph node metastases. They postulated that the extent of residual disease at radical cystectomy may be related to cancer control outcomes. Pathological stage at radical cystectomy was P0 in 11.5% of cases, Pa in 4.3%, PCIS in 10.6%, P1 in 16.8% and P2 in 56.7%. Patients with P0, Pa or PCIS disease had no recurrence at 1, 3 and 5 years. Patients with P1 disease had recurrence-free survival rates of 97%, 90% and 84.6% at 1, 3 and 5 years, respectively. The authors conclude that stage P1 or lower at radical cystectomy was an independent predictor of disease-free recurrence. These results may influence consideration given to adjuvant therapy or neoadjuvant chemotherapy to patients undergoing radical cystectomy.
Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for Chronic Pelvic Pain Syndrome
As most urologists are aware, the treatment of pelvic pain is challenging and often ineffective. FitzGerald (page 570) from Maywood, Illinois recruited patients from 6 clinical sites with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome and randomized them to either myofascial physical therapy or global therapeutic massage. The Patient Global Response Assessment in the myofascial physical therapy group was 57%, which was significantly higher than the 21% response rate in the global therapeutic massage group. The authors conclude that a full-scale trial of physical therapy methods was feasible and the preliminary findings of a beneficial effect of myofascial physical therapy especially in women with chronic pain warrants further study.
Denosumab for Prostate Cancer With Bone Metastases
In patients with bone metastases tumor cells in the bone disrupt the balance between bone resorption and bone formation. Growth factors produced by the tumor cells induce stromal cells and osteoblasts to secrete the receptor activator of the NF-κB ligand which mediates increased osteoclast formation and bone resorption. Fizazi et al (page 509) from Paris, France examined bone metastases in patients with prostate cancer and compared intravenous bisphosphonates to subcutaneous denosumab, an antibody to the NF-κB ligand which inhibits bone resorption. Urine N-telopeptide was used to assess osteoclast mediated bone resorption. All patients took daily supplements of calcium and vitamin B. Of the patients 69% on denosumab had evidence of reduction of bone resorption vs 19% in the bisphosphonate group. For patients with prostate cancer and bone metastasis, denosumab was demonstrated to be a potential therapy for the skeletal related events involved in bone metastasis.
Preliminary Evaluation of a Genitourinary Skills Training Curriculum for Medical Students
Challenges and opportunities exist for training medical students in genitourinary medicine. At most universities less than a third of students rotate through urology, and yet genitourinary complaints account for a large percentage of medical practice, especially in primary care. Kaplan et al (page 668) from Irvine, California required all 94 third-year medical students to undergo a 2-day genitourinary skills training program which included didactic lectures and video presentations as well as virtual reality sessions. Before the program fewer than 10% of the students had performed a testicular or digital rectal examination, or placed a Foley catheter. Moreover, these students reported discomfort with performing these procedures not to mention their patients. After the program, students were significantly more comfortable with the idea of performing these procedures, and nearly all of them scored the usefulness of the training as high, particularly the digital rectal and testicular examinations. The students performed well (80% to 98%) on questions pertaining to the urology content of the program. The authors demonstrate that an intensive skills training program can be effective for teaching medical students and increasing their comfort level with basic urology training. This paradigm, along with curricula on sources such as the AUA web site, represents opportunities to provide some basic knowledge of urology and skills to physicians entering other disciplines.
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