This Month in Adult Urology

Article Outline

• Sleep Disturbances After Cystectomy Lower Self-Assessed Quality of Life
• Circumcision and Reduced Risk of Self-Reported Penile Coital Injuries
• Minimal Impact of Clinical Stage on Prostate Cancer Prognosis
• Deliberately Induced E. coli 83972 Bacteriuria Protects Against Urinary Tract Infections
• Bacillus Calmette-Guerin and Risk of Progression of Bladder Cancer
• PSA at Diagnosis of Bone Metastases After Radical Prostatectomy
• Prostate Cancer Death of Men Treated With Initial Active Surveillance
• Copyright

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Sleep Disturbances After Cystectomy Lower Self-Assessed Quality of Life 

Trends in urinary diversion have changed in the last several decades from continent diversions to orthotopic neobladders, suggesting that patients would rather attempt to void in a more natural fashion, although the price of orthotopic neobladders may be urinary incontinence or bacteriuria. Thulin et al (page 198) from Stockholm, Sweden evaluated sleep disturbances in 520 patients who had undergone cystectomy and urinary diversion. Of 452 evaluable patients 37% with orthotopic neobladders reported sleep disturbances vs 22% and 14% with noncontinent and continent urostomies, respectively. Of the patients with orthotopic neobladder 56% reported nocturnal leakage vs 7% of those with continent diversion. Thus, patients should be aware of the potential for loss of sleep and nocturnal leakage when selecting orthotopic neobladder.

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Circumcision and Reduced Risk of Self-Reported Penile Coital Injuries 

It is becoming apparent that HIV transmission is more prevalent in uncircumcised than circumcised men. The reason is unclear but it has been postulated to be due to an altered local microenvironment or minor penile trauma/abrasion that facilitates transmission of the virus. In a multi-institutional report Mehta et al (page 203) provide some interesting insights in their study of self-reported penile coital injuries. Coital injury was defined as soreness, scratches, abrasions or cuts leading to bleeding. On multivariate analysis coital injury risk was lower for circumcised than uncircumcised men (OR 0.62). Other factors of increased risk were increasing age, multiple sex partners, herpes simplex virus-2 positivity and ulcers. Condom use and penile hygiene were protective. The authors suggest that the higher likelihood of minor penile injury could explain the higher HIV transmission rate.

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Minimal Impact of Clinical Stage on Prostate Cancer Prognosis 

With stage and grade migration in prostate cancer in the prostate specific antigen (PSA) screening era, Reese et al (page 114) from San Francisco, California question whether clinical stage remains an important independent variable predictive factor for survival of clinically organ confined disease. The study cohort comprised 4,899 men from the CaPSURE™ database, of whom 51.1% had cT1 lesions and 49.9% had cT2a to c lesions. Only stage cT2b was associated with biochemical recurrence. In contrast, PSA, biopsy Gleason score and percent of positive biopsy scores were associated with recurrence and adverse pathological outcomes. Most importantly, on multivariate analysis clinical stage did not help determine pathological or biochemical outcomes. This finding suggests that either clinical stage is inadequate or, given earlier cancer diagnosis, is less important for survival. Alternatively, increasing inaccurate clinical staging may explain the results.

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Deliberately Induced E. coli 83972 Bacteriuria Protects Against Urinary Tract Infections 

Recurrent urinary tract infections are extremely problematic in elderly individuals, patients with anatomic problems of the urinary tract and those with neurogenic bladder. The indiscriminate use of antibiotics has also led to increased antibiotic resistance. It is well recognized that asymptomatic bacteriuria, especially in the elderly or catheterized patients, is relatively benign. Sundén et al (page 179) from Lund, Sweden introduced a nonpathological form of Escherichia coli into the bladder of patients on clean intermittent catheterization in whom residual urine was thought to be a risk factor for cystitis. Of the patients without E. coli 83972 bacteriuria 89% eventually had pathogenic bacterial growth in the urine compared to only a few patients in the study group. In subjects given E. coli 83972 the time to urinary tract infection was significantly longer (11.3 vs 5.7 months) and there were fewer symptomatic urinary tract infections (13 vs 35) compared to controls. The scoring from asymptomatic periods did not differ for either arm. E. coli 83972, when established within the bladder, appears to be protective against episodes of recurrent urinary tract infection. This microflora manipulation strategy represents an innovative and potentially important approach to the increasing number of patients with recurrent urinary tract infections who do not respond to other measures.

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Bacillus Calmette-Guerin and Risk of Progression of Bladder Cancer 

Alkhateeb et al (page 81) from Toronto, Ontario, Canada studied 191 patients with pT1 nonmuscle invasive bladder cancer treated with bacillus Calmette-Guerin, of whom 95 (49.7%) had primary and 96 (50.3%) nonprimary tumors. For the primary vs nonprimary group, the progression rate was 24.2% vs 39.6% and the 5-year progression-free survival rate was 71.9% vs 51.5%, respectively. The authors conclude that patients with nonprimary T1 disease treated with bacillus Calmette-Guerin had a significantly higher risk of progression to muscle invasive disease than those with primary tumors. Thus, early identification of patients with T1 disease is needed to help improve tumor prognosis.

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PSA at Diagnosis of Bone Metastases After Radical Prostatectomy 

The yield of screening bone and computerized tomography in men with an initial diagnosis of low grade prostate cancer and PSA less than 20 ng/dl is low. However, few if any studies have examined PSA levels at the time of bone metastases after definitive therapy. Loeb et al (page 157) from Baltimore, Maryland examined 193 hormone naïve men in whom bone metastases developed a mean of 6 years after radical prostatectomy. Although median PSA was 31.9 ng/ml at initial diagnosis of metastatic disease, PSA was less than 10 ng/ml in nearly 26% of patients. This, unlike pretreatment PSA tests when metastases are rare at PSA less than 10 ng/ml, patients with biochemical failure after radical prostatectomy should undergo evaluation for potential metastases even if the PSA is low.

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Prostate Cancer Death of Men Treated With Initial Active Surveillance 

In a large phase 2 prospective trial of active surveillance for prostate cancer patients with favorable risk profiles were followed with serial PSA determinations every 3 months for 2 years and then every 6 months if stable. Biopsies were performed at 1 year and then every 3 to 4 years. Intervention was offered if the PSA doubling time was less than 3 years or Gleason 3+4 disease was identified on repeat biopsy. Intervention was necessary for potential disease progression in 38% of the men by 10 years. Only 5 of 453 patients had metastatic disease and died of prostate cancer. Krakowsky et al (page 131) from Toronto, Ontario, Canada studied the characteristics of these patients and concluded that the extremely low rate of cancer deaths suggested that surveillance was a reasonable therapy. Most patients who had progression were identified based on a rapid PSA doubling time. Of the 5 patients who died 2 delayed therapeutic intervention, and only 1 patient presenting with favorable disease in this trial had a theoretically preventable death.