This Month in Adult Urology

Article Outline

• Epididymectomy for Chronic Epididymal Pain
• Comparison of Shock Wave Frequencies for Upper Ureteral Stones
• Ketoconazole and Prednisone to Prevent Recurrent Ischemic Priapism
• Optical Biopsy of Human Bladder Neoplasia
• Alcohol Consumption is Associated With Decreased Risk of Benign Prostatic Hyperplasia
• Patients With Renal Transplant and End Stage Renal Disease Present With More Advanced Bladder Cancer
• Predicting Prostate Cancer Recurrence After Radical Prostatectomy
• Do Oral Antimuscarinic Drugs Increase the Risk of Acute Urinary Retention?
• Neuroendocrine Differentiation and PTEN Expression After Bicalutamide Monotherapy
• Copyright

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Epididymectomy for Chronic Epididymal Pain 

Chronic epididymal pain is frustrating for patients and problematic for physicians. A variety of treatments have been proposed with varying degrees of success. Hori et al (page 1407) from the United Kingdom retrospectively reviewed the records of 72 patients who underwent epididymectomy between 1994 and 2007 and were followed for an average of 7.4 years. Epididymectomy was performed for post-vasectomy pain in 85% of the patients and for nonvasectomy related reasons in 15%. All patients had pain on palpation of the epididymis. Postoperatively, less or no pain was experienced by 93.3% of the post-vasectomy group and improvement was noted in 75% of the non-post-vasectomy group. In properly selected patients epididymectomy may be of benefit, particularly for post-vasectomy pain, when conservative measures such as medications and counseling fail.

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Comparison of Shock Wave Frequencies for Upper Ureteral Stones 

Previous reports have suggested that lowering the frequency of shock waves increases fragmentation rates for renal calculi. However, there are reasons to believe that lower rates may not be as effective in patients with ureteral calculi. In this randomized study comparing lower shock wave frequency for ureteral stones Honey et al (page 1418) from Toronto, Ontario, Canada report overall stone-free rates at 3 months of 65% for 60 shocks per minute vs 48.8% for 120 shocks per minute (77 and 86 patients, respectively). Reducing the shock rate from 120 to 60 improves stone-free rates and may reduce the need for more invasive procedures for upper ureteral calculi.

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Ketoconazole and Prednisone to Prevent Recurrent Ischemic Priapism 

Recurrent priapism can cause tremendous morbidity such as fibrosis and permanent erectile dysfunction, and treatment can be challenging. Abern and Levine (page 1401) from New York, New York report on 8 patients with recurrent priapism treated with ketoconazole and prednisone. Prednisone was added to the regimen because of the potential for adrenal insufficiency in patients treated with ketoconazole. The authors also monitored testosterone and dosing was titrated to lower testosterone to prevent recurrent priapism yet preserve sexual function. Mean followup was approximately 1.5 years. There were 2 episodes of recurrent ischemic priapism in 1 patient. Another patient had an increase in testosterone after treatment and 3 episodes of recurrent ischemic priapism. Overall the results were respectable and the majority of patients had no episodes following treatment. The remaining patients were treated with a shunt, penile prosthesis or self-injection of phenylephrine. Of interest, the International Index of Erectile Function scores were normal in 4 patients.

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Optical Biopsy of Human Bladder Neoplasia 

Confocal laser endomicroscopy is a new imaging technology that provides in vivo high resolution histopathological information. For this pilot study Sonn et al (page 1299) from Stanford, California recruited 27 patients, of whom 9 had low grade tumors, 9 had high grade tumors, 1 had a low grade tumor with a high grade focus and 8 had no cancer. Endomicroscopic images showed clear differences between normal mucosa, and low and high grade tumors. Fluorescein was used as the contrast agent. The authors suggest that confocal laser microscopy be used as an adjunct to conventional cystoscopy. This technology could provide real-time inspection for high grade tumors including carcinoma in situ.

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Alcohol Consumption is Associated With Decreased Risk of Benign Prostatic Hyperplasia 

Parsons and Im (page 1463) from San Diego, California performed a meta-analysis of 19 studies related to alcohol intake, benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) to determine the effects of alcohol on BPH and LUTS. They noted that in 14 of 19 studies the likelihood of BPH and LUTS decreased with increased alcohol intake. Alcohol intake was stratified into 6 different amounts with the likelihood of alcohol reducing BPH for all 6 dosages. Consumption appeared to decrease the likelihood of BPH but not LUTS. Further studies are needed to determine the mechanism by which alcohol consumption modifies BPH risk.

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Patients With Renal Transplant and End Stage Renal Disease Present With More Advanced Bladder Cancer 

There may be reason to suspect that immunosuppression accompanying renal transplantation is associated with increased risk of bladder cancer or more aggressive cancer, as suggested by increased risks for nonmelanoma skin cancer, nonHodgkin's lymphoma and Karposi's sarcoma. These risks may be multifactorial. In a review of SEER-Medicare data 97,942 patients with bladder cancer were identified by Ehdaie et al (page 1482) from Charlottesville, Virginia. Of these subjects 58 underwent renal transplantation compared to 400 with end stage renal disease without renal transplantation before bladder cancer diagnosis. Patients with a renal transplant and end stage disease presented with higher stage bladder cancer despite close medical supervision. Of interest, bladder cancer presentation proximate to renal transplant suggests the possibility of screening these patients.

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Predicting Prostate Cancer Recurrence After Radical Prostatectomy 

Controversy exists regarding the prognosis of positive margins after radical prostatectomy. Previous studies suggest that only margins at certain locations, the number of margins or the extent of margin positivity may bode a worse prognosis. Stephenson et al (page 1357) review 7,160 cases treated with radical prostatectomy at 3 institutions. Followup data were analyzed using Cox proportional hazards regression analysis. The 7-year progression-free probability was 60% among patients with positive surgical margins. Positive surgical margin was associated with biochemical recurrence (HR 2.3 after adjusting for age, prostate specific antigen, Gleason score, pathological stage and year of surgery). Increased risk of biochemical progression was associated with multiple vs solitary positive margins, and extensive vs focal positive margins on multivariate analysis. However, neither parameter improved the predictive accuracy of a nomogram compared to positive vs negative margin status alone. Thus the empiric subclassification of margin status is of limited usefulness although the presence of positive margins increases the risk of biochemical recurrence.

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Do Oral Antimuscarinic Drugs Increase the Risk of Acute Urinary Retention? 

Martin-Merino et al (page 1442) from Madrid, Spain examined the records of patients with urinary retention by reviewing diagnostic codes and a random sample of questionnaires to assess whether those treated with oral antimuscarinics were at greater risk for acute urinary retention. The overall incidence of acute urinary retention was 1/1,000 person-years, with the incidence increasing with age. In the first 30 days of antimuscarinic use the relative risk of urinary retention was 8.3 (95% CI 4.8–14.2) and with longer use the relative risk was only 2.0 (95% CI, 1.2–3.1). The relative risk of acute urinary retention was similar for low and medium vs high antimuscarinic doses. It does appear that antimuscarinic use is associated with increased risk of urinary retention, especially during the first 30 days, although the definition of antimuscarinic drugs and the impact of drug interactions cannot be determined.

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Neuroendocrine Differentiation and PTEN Expression After Bicalutamide Monotherapy 

Androgen deprivation is the primary treatment for advanced prostate cancer but its effects are limited by eventual hormone refractory status. Determining what predicts hormone therapy failure may provide insight into new treatments for hormone refractory disease. Ham et al (page 1378) from Seoul, Republic of Korea analyzed expression of the tumor suppressor phosphatase and tensin homolog deleted on chromosome 10 (PTEN), human epidermal receptor (HER)-2 and neuroendocrine differentiation after bicalutamide therapy. A total of 107 radical prostatectomy specimens from patients given 150 mg bicalutamide before surgery were evaluated. Patients with minimal regression effects after bicalutamide had an advanced pathological stage and tended to have positive chromogranin A expression and PTEN inactivation. Only 3.7% of the prostatectomy specimens showed HER-2 immunostaining. The probability of positive chromogranin expression in the PTEN inactivation group was 2.5-fold higher than in the nonPTEN inactivation group. Cox regression analysis revealed that seminal vesicle invasion, PTEN/chromogranin expression and lymph node invasion were significant variables for time to biochemical recurrence. Thus PTEN inactivation and neuroendocrine differentiation were related to refractoriness to bicalutamide therapy.