This Month in Adult Urology

Article Outline

• Hospital Admission Rates and Urological Complications of Prostate Biopsy
• PSA Decrease and Prostate Cancer Diagnosis: Antibiotic Versus Placebo Prospective Randomized Clinical Trial
• Robotic Assisted Laparoscopic Versus Radical Retropublic Prostatectomy for Localized Prostate Cancer
• Urodynamic Effects of Once Daily Tadalafil for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia
• Do Biomechanical Properties of Anterior Vaginal Wall Prolapse Tissue Predict Outcome of Surgical Repair?
• Is Type 2 Diabetes Mellitus a Predicting Factor for Incontinence After Laparoscopic Radical Prostatectomy?
• A Novel Drug Eluting Ureteral Stent
• Impact of Positive Surgical Margins on Mortality After Radical Prostatectomy During the PSA Era
• Prevalence of Urolithiasis in Asymptomatic Adults
• Copyright

Back to Article Outline

Hospital Admission Rates and Urological Complications of Prostate Biopsy 

In this population based study Nam et al (page 963) from Ontario, Canada reviewed hospital admission rates for complications from prostate biopsy between 1996 and 2005. Of 75,190 men who underwent transrectal ultrasound guided biopsy 45% were diagnosed with prostate cancer. The hospital admission rate for complications within 30 days of the procedure for men without cancer was 1.9%. However, the 30-day hospital admission rate increased from 1% in 1996 to 4.1% in 2005. Thus the probability of being admitted to the hospital within 30 days of having the procedure increased 4-fold between 1996 and 2005 (odds ratio 3.7, 95% CI 2.0–7.0, p <0.0001). Fortunately the overall 30-day mortality rate was 0.09% and did not change during the study period. The authors postulate a variety of reasons for the increase in complication rate, including an increase in antibiotic resistant pathogens and the greater number of needle cores taken at biopsy. They also speculate that mortality has not increased because of improved treatments for sepsis.

Back to Article Outline

PSA Decrease and Prostate Cancer Diagnosis: Antibiotic Versus Placebo Prospective Randomized Clinical Trial 

Many men diagnosed with prostatitis or pelvic pain syndrome have increased serum prostate specific antigen (PSA) levels. Stopiglia et al (page 940) from Sao Paulo, Brazil performed a prospective randomized trial of antibiotic versus placebo for men with increased PSA and type IV asymptomatic prostatitis. Type IV prostatitis was diagnosed based on greater than 10 white cells per high power field or greater than 20 white cells after prostatic massage. The authors found no significant difference in terms of patient age and pretreatment PSA between those allocated to antibiotics vs placebo, and no difference between those with and without prostate cancer on biopsy. Of the placebo group 59% had a decrease in PSA (average PSA declined 21% in 65% and normalized in 35%). Of the antibiotic group 53% had a decrease in PSA (average PSA declined 22% in 65% and normalized in 35%). Of the patients in both groups 31% had prostate cancer on biopsy. The decrease in PSA and rates of cancer were not significantly different between the placebo and antibiotic groups. Of the patients with prostate cancer the majority had Gleason 6 T1C disease. The authors conclude that antibiotic use for type IV prostatitis does not result in greater decrease in PSA than placebo. Moreover, whether PSA was reduced or not, prostate biopsy is warranted because of the substantial prevalence of cancer.

Back to Article Outline

Robotic Assisted Laparoscopic Versus Radical Retropublic Prostatectomy for Localized Prostate Cancer 

Barocas et al (page 990) from Memphis, Tennessee evaluated 491 patients treated with open radical retropubic prostatectomy (RRP) and 1,413 treated with robotic assisted laparoscopic prostatectomy (RALP). For the RRP group the 3-year biochemical recurrence-free survival rate was 83.5%, 93.7% for patients with pT2, 95.1% for those with Gleason score 5–6 and 79.6% for those with a Gleason score of 7. For the RALP group the 3-year biochemical recurrence-free survival rate was 84%, 88.2% to 96.7% for patients with pT2 disease, 98.1% for those with Gleason score 5–6 and 74.8% for those with a Gleason score of 7. The authors conclude that there is essentially no difference in cancer control between RRP and RALP based on risk factors.

Back to Article Outline

Urodynamic Effects of Once Daily Tadalafil for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia 

Recently it has been suggested that tadalafil has a therapeutic effect on lower urinary tract symptoms attributed to benign prostatic hyperplasia measured by the International Prostate Symptom Score (I-PSS). However, previous studies have shown that patients with improved I-PSS on tadalafil had no increase in flow rates. Because of the close association between symptoms of hyperplasia and erectile dysfunction, Dmochowski et al (page 1092) performed a randomized, double-blind, placebo controlled clinical trial at 20 centers during which 101 patients were randomized to receive placebo and 99 received 20 mg tadalafil daily. No differences were found in maximum urinary flow rate, maximum detrusor pressure, bladder outlet obstruction index, bladder capacity, residual urine or detrusor overactivity. Thus although men receiving tadalafil report significant improvements in I-PSS, even high dose tadalafil did not provide any apparent effect on any urodynamic parameter tested. The authors were able to refute the contention that the apparent effect of tadalafil to reduce urinary frequency was not due to a worsening of detrusor function as some have postulated.

Back to Article Outline

Do Biomechanical Properties of Anterior Vaginal Wall Prolapse Tissue Predict Outcome of Surgical Repair? 

Debate continues on what factors are responsible for not only the development of vaginal wall prolapse, but its recurrence following surgery. Investigators have suggested that changes in biomechanical properties of pelvic tissues predispose to anterior vaginal wall prolapse. Gilchrist et al (page 1069) from Dallas, Texas questioned whether vaginal tissue properties were predictive of failure following prolapse repair. They examined 32 patients with a median age of 72 years for evidence of changes in biochemical properties. At the time of vaginal wall repair, tissue was subjected to biomechanical testing and the Young modulus was calculated representing tissue strength. Surgery failed in 7 of the 32 patients. However after performing detailed multivariate analysis, the authors could not find any difference in the Young modulus, such as an increase in compliance, to explain the failures.

Back to Article Outline

Is Type 2 Diabetes Mellitus a Predicting Factor for Incontinence After Laparoscopic Radical Prostatectomy? 

In this matched pair and multivariate analysis Teber et al (page 1087) from Germany and Turkey evaluated the effect of diabetes on rate of urinary incontinence and the time to achieve continence following laparoscopic radical prostatectomy. Patients with vs those without type 2 diabetes took a longer time to recover. Age and duration of diabetes were predictive of post-prostatectomy incontinence. The authors urge that better metabolic control be obtained for patients with type 2 diabetes before prostatectomy in an effort to potentially reduce the postoperative incontinence rate.

Back to Article Outline

A Novel Drug Eluting Ureteral Stent 

Pain is common when ureteral stents are inserted following ureteroscopy. The development of stents coated with materials that may reduce pain could improve outcomes. In this multicenter trial by Krambeck et al (page 1037) a stent coated with ketorolac was inserted into 276 patients. The primary study end point was intervention for pain, including physician appointment, change in medication or early stent removal. Secondary study end points were medication use and pain measured on a visual analog score. There was no statistically significant difference in either primary or secondary outcomes of the 276 patients. Therefore, the authors conclude that, although safe, the ketorolac coated stent did not improve patient discomfort.

Back to Article Outline

Impact of Positive Surgical Margins on Mortality After Radical Prostatectomy During the PSA Era 

Using the Mayo Clinic Prostatectomy Registry Boorjian et al (page 1003) evaluated the records of more than 11,000 patients followed for a mean of 8 years after radical prostatectomy, of whom 31% had positive surgical margins. The biochemical recurrence-free rate differed between positive (56%) and negative (77%) margins. There was no difference on multivariate analysis in cancer specific survival, prediction of systemic progression or overall mortality. Thus, although positive surgical margins increase biochemical recurrence rates, the authors could not demonstrate an adverse effect on survival. They warn that this finding may be due to the length of followup and other yet unidentified variables.

Back to Article Outline

Prevalence of Urolithiasis in Asymptomatic Adults 

The prevalence of urolithiasis in asymptomatic individuals is unknown. In addition, risk factors for the development of stone disease are often based on patients presenting to the clinic with symptoms. Boyce et al (page 1017) from Madison, Wisconsin examined low dose, noncontrast computerized tomography scans obtained from 5,047 consecutive asymptomatic adults between 2004 and 2008. The prevalence of urolithiasis was 7.8% but the incidence of symptomatic urolithiasis during a 10-year period was 21% (81 of 395 patients). Although obesity and diabetes are risk factors for urolithiasis, they were not significantly associated with symptomatic stone disease. Only male gender was a risk factor for the overall prevalence of urolithiasis at screening (9.7% vs 6.3% of women).