The Journal of Urology
Volume 182, Issue 6 , Pages 2545-2547, December 2009

This Month in Adult Urology

published online 20 October 2009.

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Intravesical Prostatic Protrusion Among Men in Olmsted County, Minnesota 

Benign prostatic enlargement places patients at risk for retention and lower urinary tract symptoms (LUTS). It has been suggested that protrusion of the prostate into the bladder, which can be measured by ultrasound, correlates with bladder outlet obstruction and may independently influence therapeutic decisions based on outcomes. Lieber et al (page 2819) from Rochester, Minnesota performed transrectal ultrasound examination of 322 men for intravesical prostatic protrusion based on cross-sectional evaluation. Patients with greater than 10 mm protrusion were more likely to suffer from and take medication for LUTS compared to men without such protrusion (OR 3.25; 95% CI 1.53, 6.93). The authors conclude that intravesical prostatic protrusion correlates to prostatic volume, obstructive symptoms, prostate specific antigen (PSA) level and decreasing peak urinary flow rate, and may predict the need for urodynamics.

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Sacral Neuromodulation Versus Intravesical Botulinum A Toxin for Refractory Urge Incontinence 

The treatment of urinary urge incontinence that fails to respond to antimuscarinics is a challenge. Sacral nerve modulation has been proven to reduce symptoms in a screened population of patients. Newer data suggest that botulinum A toxin may be as effective but the drug is costly and not approved the Food and Drug Administration. Siddiqui et al (page 2799) from Durham, North Carolina developed a Markov decision model using a societal perspective to compare costs and effectiveness. They calculated the quality of adjusted life years and incremental cost-effectiveness ratio, and found that sacral neuromodulation was more expensive and more effective than botulinum A toxin (neuromodulation cost-effective ratio $116,427 per quality of adjusted life years). During a 2-year period botulinum toxin A appeared to be more cost-effective than sacral nerve modulation based on currently published data in the literature for refractory urge incontinence. The authors warn that the long-term effectiveness of repeat injections remains unclear.

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Effect of Chronic Sildenafil on Penile Endothelial Function 

Endothelial dysfunction is a major etiological factor in the development of vasculogenic erectile dysfunction. There is reason to suspect that chronic treatment with phosphodiesterase type 5 inhibitors may improve endothelial function in individuals with cardiovascular disease. Thus Vardi et al (page 2850) from Haifa, Israel randomized 60 men to receive either placebo or sildenafil for 5 weeks and then measured parameters of endothelial function including penile and forearm blood flow. Baseline penile blood flow was 6.2 ± 1.4 ml per minute per dl in the placebo group and 7.0 ± 0.6 ml per minute per dl in the sildenafil group. After treatment for 4 weeks, penile blood flow in the sildenafil group increased to 11.2 ± 2 ml per minute per dl tissue and was unchanged in the placebo group. The area under the curve for sequential changes in maximal blood flow increased to 720 ± 65 in the sildenafil group and remained unchanged in the placebo group. Forearm blood flow was unaffected by placebo and sildenafil. The authors conclude that daily sildenafil improves penile blood flow and penile endothelial indices without systemic side effects. Thus, men on chronic phosphodiesterase type 5 inhibitors may experience beneficial effects on the systemic vasculature.

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Polyvinylchloride Versus Polyvinylchloride-Free Catheter Materials 

Despite the universal acceptance of clean intermittent catheterization by health care providers, patients often complain of difficulty or discomfort using catheters. Many studies have compared sterile vs clean techniques, coated vs uncoated catheters and single vs multiple use. It is unclear whether any one catheter type, technique or strategy is better than another. In a multi-institutional study Witjes et al (page 2794) compared a low friction catheter consisting of polyvinylchloride (PVC), and a hydrophilic layer of polyvinylpyrrolidone and sodium chloride with a catheter consisting of a PVC-free material, polyolefin based elastomer, and the same hydrophilic layer. Patients were randomized to one or the other catheter for 4 weeks. Both catheters were identical in appearance. Patient satisfaction and comfort were scored by questionnaires. Before randomization 94% to 98% of patients rated the PVC catheter as easy or manageable to handle during catheterization and 92% were satisfied. Satisfaction was reported by 89% randomized to continue using a PVC catheter and 78% randomized to switch to the PVC-free catheter. The difference was not statistically significant. Conversion from the low friction PVC catheter to the PVC-free catheter did not appear to alter patient perceptions about catheterization. When randomized, patients seemed comparably satisfied with either catheter.

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Risk Factors Associated With Urge Incontinence After Continence Surgery 

While many surgeries have been used to treat urinary incontinence, a frustrating outcome is postoperative de novo urinary urge incontinence (UUI). As part of the prospective randomized trial of Burch vs fascial sling procedures (Stress Incontinence Surgical Treatment Efficacy Trial) Kenton et al (page 2805) report the results of secondary analyses performed to ascertain which if any preoperative variables could predict postoperative UUI. Postoperative UUI was considered significant if treatment was required 6 weeks or more after surgery. Bivariate logistic regression models were fit in which each covariate was controlled for separately, including age, body mass index, prior incontinence surgery, prior anticholinergic medication, prolapse state, stress and urge symptom scores, detrusor overactivity and maximum detrusor pressure flow. Postoperative treatment of UUI was necessary in 21% of women (after a Burch procedure in 50 and after a sling in 82). The odds of postoperative UUI were higher after a sling procedure vs a Burch procedure. A 10-point increase in preoperative MESA urge score, prior anticholinergics and detrusor overactivity also independently increased the odds of postoperative UUI. These data should be useful for surgeons informing patients of the risks of UUI after these surgeries for stress incontinence. Whether these parameters also predict UUI after other surgeries merits study.

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Low Annual Caseloads of United States Surgeons Performing Radical Prostatectomy 

It is well-known that surgeons performing complex urological procedures more frequently have lower rates of complications. Some reports have even shown that at least 250 radical prostatectomies are needed to overcome the surgical learning curve. Savage and Vickers (page 2677) from New York, New York examined 2 independent data sets, the NIS (Nationwide Inpatient Sample) and a complete record of all discharges from New York State. They identified 6,621 patients who had undergone radical prostatectomy in 2005 by 933 surgeons from the NIS and less than 4% of surgeons had annual caseloads that would allow them to reach the learning curve plateau within 10 years (at least 25 surgeries per year). More than a quarter of physicians performed only a single procedure annually and approximately 80% of surgeons performed 10 or fewer procedures. The authors conclude that many patients are being treated by surgeons with inadequate experience. However as mentioned in an accompanying editorial, many less experienced surgeons may be assisted by surgeons with more experience and the impact of such assistance is unclear.

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Influence of Psychiatric Comorbidities and Sexual Trauma on Lower Urinary Tract Symptoms in Female Veterans 

The adverse influence of emotional stress on LUTS has long been postulated but it is becoming the target of recent studies. Stress has been thought to be associated with an overactive bladder. Klausner et al (page 2785) from Richmond, Virginia evaluated urinary tract symptoms, and administered UDI-6 (Urogenital Distress Inventory) and IIQ-7 (Incontinence Impact) questionnaires to female veterans in a VA hospital setting. The results were then compared to those of a control population of women seen in a primary care clinic. Women referred for evaluation of LUTS had a higher rate of psychiatric comorbidities (64.5% vs 25.9%) and sexual trauma (49.6% vs 20.1%) than the control group. UDI-6 and IIQ-7 scores were significantly higher for patients with psychiatric comorbidities and sexual trauma. The authors conclude that psychiatric comorbidities and sexual trauma are extremely prevalent in women presenting for LUTS and have a severe quality of life impact.

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Predictors of Positive Surgical Margins After Laparoscopic Robot Assisted Radical Prostatectomy 

Positive tumor margins after radical prostatectomy are associated with PSA biochemical failures. After robotic radical prostatectomy, rates of positive surgical margins range from 11% to 36%. Ficarra et al (page 2682) from Padua, Italy evaluated potential factors influencing positive margin rates in 322 patients who underwent laparoscopic robot assisted prostatectomy for prostate cancer without prior hormonal therapy. Positive surgical margins were found in 29.5% of patients. Prostate volume on transrectal ultrasound and clinical T stage were independent predictors of the presence of any positive surgical margins in the entire cohort of patients. T stage and biopsy Gleason score were also predictors of posterolateral positive surgical margins. Of the pathological variables extraprostatic extension was an independent predictor of any positive surgical margins and posterolateral positive surgical margins. Perineural invasion was an independent predictor of any positive surgical margins in organ confined disease with a statistically insignificant trend for posterolateral positive surgical margins. The authors conclude that pathological extension of the primary tumor is the only relevant tumor characteristic that predicts positive surgical margins. However, it is unclear from this report how much effect the level of surgeon experience also had on positive margin rates, which is a modifiable factor separate from tumor biology.

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Serial Prostate Biopsies and Risk of Erectile Dysfunction During Active Surveillance for Prostate Cancer 

Needle biopsies of the prostate are considered to be relatively benign except for risk of infections and bleeding complications. Thus, it was interesting that Fujita et al (page 2664) from Baltimore, Maryland found that SHIM (Sexual Health Inventory for Men) scores were lower than baseline in men after 3 biopsies. The authors conclude that serial prostate biopsies may have an adverse effect on erectile function in men under prostate cancer surveillance but do not affect LUTS. However, it is unclear whether anxiety about future cancer diagnoses could also impact these scores as opposed to injury from repeated biopsies as inferred from this study.

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Effects of Denosumab on Bone Mineral Density 

Androgen deprivation therapy and bilateral orchiectomy for prostate cancer have long been associated with osteoporosis among other morbidities. Treatment with bisphosphonates can also result in significant morbidity including gastrointestinal distress and jaw necrosis. Biological agents such as denosumab, a fully human monoclonal antibody against RANKL, a key mediator of osteoclast formation, have been given to men on androgen deprivation therapy as another approach to treating osteoporosis. In a multi-institutional study Smith et al (page 2670) report on 1,468 patients randomized to receive 60 mg denosumab or placebo every 6 months for 36 months. Denosumab significantly increased bone mineral density after 36 months. Increased density was associated with lower bone loss and risk of fractures. A novel aspect of this biological therapy is that serum C-telopeptide can be measured as a sensitive marker for bone turnover. After further study and if approved by the Food and Drug Administration, denosumab may provide treatment and/or prevention of osteoporosis in men undergoing androgen deprivation therapy.

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Validation of the Prostate Cancer Prevention Trial Calculator 

Risk calculators are now the rage for a wide range of surgeries such as colorectal cancer or heart surgery as well as predicting cancer risks. The Prostate Cancer Prevention Trial (PCPT) risk calculator was developed to assess the risk of prostate cancer based on PSA, digital rectal examination results, age, race and family history of prostate cancer in a multivariable model. Because the PCPT trial may have enrolled a low risk population, Eyre et al (page 2653) sought to assess the generalizability of the PCPT calculator in a more representative selection of patients referred for consideration of prostate biopsy. Patients were enrolled in the study by 12 urologists at 5 sites in an Early Detection Research Network (EDRN) cohort. The PCPT calculator was evaluated by examining the area under the receiver operating characteristic curve, sensitivity, specificity and calibration comparing observed vs predicted risk of prostate cancer detection. Cancer incidence was greater in the EDRN validation cohort (43%) compared to the PCPT group (22%). Cancer severity (higher grade disease) was worse in the EDRN group in which patients were younger and more racially diverse, and had more abnormal digital rectal examinations and higher PSA levels than those in the PCPT group. The PCPT risk calculator was superior to PSA alone for predicting cancers in the EDRN group (AUC 0.691 vs 0.655, p = 0.009) and calibration confirmed that the PCPT risk score accurately predicted individual risks in the EDRN group. The authors conclude that the PCPT risk calculator can be applied to measure the risk of prostate cancer detection in routine urology practice to advise patients of the risk of prostate cancer and the need for a prostate biopsy.

PII: S0022-5347(09)02439-2

doi:10.1016/j.juro.2009.09.025

The Journal of Urology
Volume 182, Issue 6 , Pages 2545-2547, December 2009

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