This Month in Adult Urology

Article Outline

• Lifelong Yearly Prostate Specific Antigen Surveillance
• Prevalence of Urinary Incontinence in United States Men
• Post-Radical Prostatectomy Inguinal Hernia
• Smaller Prostate Predicts High Grade Prostate Cancer
• Efficacy of Nondrug Lifestyle Measures for the Treatment of Nocturia
• Long-Term Effect of Early Postoperative Pelvic Floor Biofeedback on Continence
• Effect of Weight Loss on Urinary Incontinence in Women
• Copyright

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Lifelong Yearly Prostate Specific Antigen Surveillance 

Tollefson et al (page 925) from Rochester, Minnesota question the need for frequent monitoring of patients with low risk prostate cancer. To defend this practice, data from the records of 2,219 patients undergoing surgery between 1994 and 2004 were analyzed using a definition of low risk as prostate specific antigen (PSA) less than 10, pathological stage T2c or less and Gleason score 6 or less with negative lymph nodes and negative margins. Only 142 patients experienced biochemical failure within the study end points. The risk of biochemical failure decreased with increasing duration of the PSA-free interval. Patients at 1, 3 and 5 years had cumulative biochemical failure rates of 1.8%, 4.2% and 6.3%. For patients with undetectable PSA at 5 years biochemical failure rates at 10 years were essentially 0. The risk of biochemical failure was proportionate to the PSA-free interval in low risk patients. The authors suggest that PSA measurements at 2 years would capture the majority of low risk cases that progress.

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Prevalence of Urinary Incontinence in United States Men 

To estimate the prevalence of urinary incontinence in adult United States males, Markland et al (page 1022) from Birmingham, Alabama analyzed data from 5,297 men older than 20 years who participated in the 2005–2006 and 2007–2008 cycles of the NHANES (National Health and Nutrition Examination Survey), a cross-sectional nationally representative survey of the United States noninstitutionalized population. The authors used a validated 2-item incontinence survey instrument to define incontinence, which questioned frequency of urine leakage episodes as well as the amount of leakage. The responses were multiplied to obtain a severity score. The prevalence of moderate to severe incontinence increased with age from 0.7% of men 20 to 34 years old to 16% of those 75 years old or older. Urge incontinence appeared to be the most common type. There was no difference in prevalence by racial or ethnic groups. Factors associated with urinary incontinence were age, major depression and hypertension. The authors note that this is the first study to identify the prevalence of incontinence in community dwelling men in the United States.

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Post-Radical Prostatectomy Inguinal Hernia 

Inguinal hernias develop after radical retropubic prostatectomy in 15% to 20% of men. The rate of de novo hernias is similar for open and laparoscopic procedures. To reduce the incidence of inguinal hernias, Stranne et al (page 984) from Göteborg, Sweden placed a single figure-of-8 suture at the internal ring at completion of prostatectomy using patients as their own controls with the intervention performed on 1 side only. The incidence of inguinal hernia was then compared for the intact vs the operated side. The incidence of inguinal hernia was 3.5% on the intervention side but 9.1% on the control side. The procedure added 5 to 10 minutes to the duration of the surgery. This simple procedure may provide prophylactic benefit, especially for patients at high risk for hernias.

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Smaller Prostate Predicts High Grade Prostate Cancer 

Data from the Prostate Cancer Prevention Trial suggest a possible association between prostate size and cancer grade. This finding led Newton et al (page 930) from Nashville, Tennessee to analyze data from 2,880 patients who underwent prostate cancer surgery between January 2000 and June 2008. Multivariate analysis was performed to assess prostate size as an independent predictor of higher grade cancer. After adjusting for age, race, clinical stage, biopsy Gleason score and date of surgery, the authors found that the larger prostate was associated with less likelihood of high grade disease (OR 0.94; 95% CI 0.92, 0.97) per 2 gm increments. Although multiple theories have been proposed, it is unclear why men with smaller prostates can be expected to have higher grade disease.

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Efficacy of Nondrug Lifestyle Measures for the Treatment of Nocturia 

Nocturia is a common and bothersome lower urinary tract symptom often associated with increased age and a marker for premature death. Soda et al (page 1000) from Kyoto, Japan tested the efficacy of a lifestyle modification that included restricting fluid intake in the evening, refraining from excess hours in bed, moderate daily exercise and keeping warm in bed. The frequency volume chart, International Prostate Symptom Score and Pittsburgh Sleep Quality Index were used as outcome measures before and 4 weeks after therapy. Mean number of nocturnal voids and nocturnal urine volume significantly decreased from 3.6 to 2.7 and from 923 to 768 ml, respectively. Of 56 patients 26 (53.1%) had improvement of more than 1 episode. The treatment was even more effective for patients with excessive 24-hour urine production. These nondrug lifestyle measures appear to be as effective, or possibly even more effective, than pharmacological agents to reduce nocturia. Although most of the subjects in this study were men, it would be interesting to study whether this approach would be equally effective in women as nocturia occurs more frequently in them.

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Long-Term Effect of Early Postoperative Pelvic Floor Biofeedback on Continence 

Ribeiro et al (page 1034) from Sao Paulo, Brazil randomized 73 patients to undergo post-prostatectomy intervention with pelvic muscle biofeedback training once a week for 3 months vs no training. Patients were evaluated at 1, 3, 6 and 12 months. Continence was defined as 1 pad or none a day. In addition to pads, incontinence symptoms and quality of life were assessed. At 12 months 25 patients in the treatment group (96%) were continent vs 21 (75%) in the untreated group. Absolute risk reduction was 21%. Interestingly, the quality of life improved in both groups at 1 year. The biofeedback pelvic muscle training hastened recovery and improved continence. Accumulating evidence suggests that pelvic muscle training should be recommended for all patients undergoing radical prostatectomy.

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Effect of Weight Loss on Urinary Incontinence in Women 

Previous results from the Program to Reduce Incontinence by Diet and Exercise group have indicated significant reductions in urine loss and stress urinary incontinence with a corresponding weight loss at 6 months in a trial of overweight and obese women. Short-term data revealed a decrease in mean weekly incontinence episodes. Wing et al (page 1005) update their experience, reporting 12 and 18-month results. At 12 months the intervention group had a greater percent reduction in stress urinary incontinence episodes than the control group (65% vs 47%, p<0.001), and a greater proportion achieved at least 70% decrease in weekly total and stress incontinence episodes. At 18 months a greater proportion of women in weight loss intervention had greater than 70% improvement in urge incontinent episodes but there were no significant differences between groups for stress or total incontinence. This latter finding was not due to stress urinary incontinence recurrence, but rather to an unexplained improvement in the control group.