Can We Predict a Higher Risk of Urothelial Bladder Cancer With a Simple Blood Test?

BACKGROUND/AIM

The COVID-19 pandemic highlighted the need to develop tools prioritizing high risk patients for urgent evaluation. Our objective was to determine whether Glasgow Prognostic Score (GPS), an inflammation-based score, can predict higher grade and stage urothelial bladder cancer in patients with gross hematuria who need urgent evaluation.

PATIENTS AND METHODS

We analyzed a database of 129 consecutive patients presenting with gross hematuria. GPS was calculated using pretreatment C-reactive protein (CRP) and albumin levels. Patients with bacteriuria or other known malignancies were excluded. The relationship between GPS and final diagnosis was analyzed with multivariate logistic regression.

RESULTS

A total of 101 patients were included in the study and 24 patients were identified without any pathology and 77 with a bladder tumor. Pathology demonstrated 21 with muscle invasive, 18 with high grade non-muscle invasive, and 38 with low grade superficial bladder cancer. Twenty-six of 39 (67%) patients with high grade tumors had a GPS of 1 or 2 compared to only 8 out of 62 (13%) patients with either low grade or negative findings (p<0.0001). Ten of 21 (48%) patients with muscle invasive disease had a GPS of 2 compared to 1 out of 18 (6%) with high grade non muscle invasive tumors (p=0.04). On multivariate analysis, GPS was a strong independent predictor of high grade and stage bladder cancer.

CONCLUSION

GPS may serve as a highly accessible predictor of high grade, high stage, and large urothelial bladder tumors at the time of initial evaluation and can help identify patients who need urgent evaluation.

Preoperative 68Ga-PSMA PET/CT defines a subgroup of high-risk prostate cancer patients with favorable outcomes after radical prostatectomy and lymph node dissection

BACKGROUND

High-risk prostate cancer is associated with adverse pathology and unfavorable outcomes after radical prostatectomy. ⁶⁸Ga-PSMA PET/CT is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether lymph node involvement on ⁶⁸Ga-PSMA PET/CT prior to radical prostatectomy in patients with high-risk prostate cancer is associated with worse short-term oncologic outcomes.

METHODS

We retrospectively reviewed 149 patients with high-risk localized or locoregional prostate cancer who underwent ⁶⁸Ga-PSMA PET/CT prior to radical prostatectomy between 2015 and 2020. None of the patients received neoadjuvant or adjuvant treatment. The study endpoints were PSA persistence and biochemical recurrence. Logistic regression models were used to identify preoperative predictors of PSA persistence. Kaplan-Meier analyses were used to estimate biochemical recurrence-free survival.

RESULTS

Of 149 identified patients, 19 (13%) were found to have lymph node involvement on preoperative ⁶⁸Ga-PSMA PET/CT. The sensitivity, specificity, and accuracy of ⁶⁸Ga-PSMA PET/CT for identifying pathologic lymph node involvement were 68%, 95%, and 92%, respectively. PSA persistence rate was lower among patients with PET-negative lymph nodes than those with PET-positive nodes (15 vs. 84%, p < 0.001). Positive nodes on imaging (OR = 41.03, p < 0.001) and clinical T2c-T3 stage (OR = 6.96, p = 0.002) were associated with PSA persistence on multivariable analysis. Among patients with PET-negative nodes the 1- and 2-year biochemical recurrence-free survival rates were 87% and 76%, respectively.

CONCLUSIONS

Preoperative staging with ⁶⁸Ga-PSMA PET/CT may identify a subgroup of high-risk prostate cancer patients with favorable short-term outcomes after radical prostatectomy without adjuvant treatment. Future studies will evaluate whether these results are sustained during long-term follow-up.

The effect of delaying transperineal fusion biopsy of the prostate for patients with suspicious MRI findings-Implications for the COVID-19 era

Objective

Image guided biopsies are an integral part of prostate cancer evaluation. The effect of delaying biopsies of suspicious prostate mpMRI lesions is uncertain and clinically relevant during the COVID-19 crisis.

We evaluated the association between biopsy delay time and pathologic findings on subsequent prostate biopsy.

Materials and methods

After obtaining IRB approval we reviewed the medical records of 214 patients who underwent image-guided transperineal fusion biopsy of the prostate biopsy between 2017 and 2019.

Study outcomes included clinically significant (ISUP grade group ≥2) and any prostate cancer on biopsy. Logistic regression was used to evaluate the association between biopsy delay time and outcomes while adjusting for known predictors of cancer on biopsy.

Results

The study cohort included 195 men with a median age of 68. Median delay between mpMRI and biopsy was 5 months, and 90% of patients had a ≤8 months delay. A significant association was found between PI-RADS 5 lesions and no previous biopsies and shorter delay time.

Delay time was not associated with clinically significant or any cancer on biopsy. A higher risk of significant cancer was associated with older age (P = 0.008), higher PSA (0.003), smaller prostate volume (<0.001), no previous biopsy (0.012) and PI-RADS 5 lesions (0.015).

Conclusions

Our findings suggest that under current practice, where men with PI-RADS 5 lesions and no previous biopsies undergo earlier evaluation, a delay of up to 8 months between imaging and biopsy does not affect biopsy findings.

In the current COVID-19 crisis, selectively delaying image-guided prostate biopsies is unlikely to result in a higher rate of significant cancer.

High cancer detection rate using cognitive fusion - targeted transperineal prostate biopsies

Objective

MRI of the prostate improves diagnostic accuracy of prostate cancer. Different fusion approaches with transrectal ultrasound images are employed.

Objective

To determine detection rate of prostate cancer in men undergoing transperineal MRI-based cognitive fusion biopsy.

Materials and Methods

One hundred and sixty-four consecutive men underwent a multiple-core prostate transperineal biopsy. Univariable and multivariable logistic regression analyses were used to address the relationship between clinical parameters and prostate cancer detection rate.

Results

One hundred and fourteen patients underwent mpMRI prior to the transperineal biopsy, 52 (45%) were diagnosed with prostate cancer, of them, 36 had Gleason score ≥7 (69%). Among these 114 patients, 82 had suspicious lesions on MRI, and 43 of them were diagnosed with cancer (52%). On multivariate analysis, the most significant independent predictive factors were PSA density (P<0.001) and suspicious MRI lesion (P=0.006). Men with a PSA density of more than 0.22 and a suspicious lesion on MRI had a detection rate of 78%. Detection rate among 50 patients with no MRI study prior to this biopsy was 26%.

Conclusions

This study showed that among a group of mostly multi-biopsied patients, the presence of mpMRI lesions and high PSA density values helped to detect clinically significant prostate cancer using cognitive MRI/TRUS fusion biopsies.

Can urologists accurately stage and grade urothelial bladder cancer by assessing endoscopic photographs?

Introduction

Assessment of urothelial bladder cancer during cystoscopy or transurethral resection of bladder tumour has a significant impact on the urologist's decision-making: treatment with simple outpatient fulguration, required depth of resection, and need of immediate post-surgical intravesical therapy. These choices depend heavily on the urologist's ability to accurately assess pre-biopsy tumour stage and grade. The aim of the study was to determine whether evaluation of photographs taken during transurethral resection of bladder tumour can reliably characterize a tumour’s stage and grade.

Methods

Smartphone photographs of 50 urothelial bladder cancer cases were taken at the beginning of transurethral resection of bladder tumour and individually presented to seven senior urologists. All urologists were blinded to the final pathological report and to any other urological evaluation. Each one was asked to rate the tumour as low vs high grade and noninvasive Ta vs noninvasive T1 or muscle invasive. Results were compared with final pathology. Individual appraisal and the majority's opinion were evaluated.

Results

Urologists have correctly predicted tumour stage and grade in 63.5% of cases (222 of 350, average of 32 out of 50 accurate assessments). The final majority assessment was correct in 40 of 50 cases (80%). Sensitivity and specificity of the final results for the diagnosis of T1 or higher were 80% and 88.6%, respectively. Sensitivity and specificity for Ta low grade were 83.3% and 80%, respectively.

Conclusions

To the best of our knowledge, this is the first documented attempt to evaluate urologists' ability to assess urothelial bladder cancer stage and grade using endoscopic photographs. Urologists can usually identify stage and grade of urothelial bladder cancer but accuracy increases when multiple senior urologists examine the same photographs and achieve majority consensus. Presenting photographs of urothelial bladder cancer to a team of urologists may lead to an excellent decision regarding type and extent of surgical treatment and substantiate appropriate post-surgical management.

Upper Calyx Accessibility Through a Lower Calyx Access Is Not Influenced by Morphometric and Clinical Factors in Supine Percutaneous Nephrolithotomy

OBJECTIVE

To assess whether morphometric and clinical parameters influence accessibility to the upper calyx through a lower calyx tract during supine percutaneous nephrolithotomy (SPCNL).

PATIENTS AND METHODS

Data for 114 consecutive SPCNLs performed between June 2014 and March 2016 in an academic medical center were analyzed. Successful approachability was defined as rigid nephroscopic access to the upper calyx introduced through a lower calyx access as attested by direct visualization of the upper calyx papillae and position of the nephroscope on intraoperative pyelography. Demographic, morphometric, and clinical parameters were assessed. Analysis of variance, Fisher's exact, chi-square tests, and univariate and multivariate models were applied.

RESULTS

Successful approach was achieved in 94 (82%) patients. In univariate analyses previous kidney operations (p = 0.03), body weight (p = 0.04), and acute lower calyx access to the upper calyx axis angle (p = 0.01^E-13) correlated with failed access. Multivariate analyses revealed that an acute angle was the sole independent factor for failed access (odds ratio [OR] 1.4, p < 0.05; confidence interval [95% CI] 1.021, 2.035). Limitations include the inability to objectively determine the mobility of the kidney as a co-factor in successful approachability.

CONCLUSIONS

SPCNL offers effective endoscopic accessibility through a lower calyx access. Previous kidney operations and body weight tend to negatively influence this accessibility. An acute angle between the lower calyx and the upper calyx is the single independent factor associated with failed accessibility.

Implementation of supine percutaneous nephrolithotomy: a novel position for an old operation

Introduction

Supine percutaneous nephrolithotomy (PCNL) has become increasingly widespread during the last 2 decades.

The aim of this study was to analyze the transition from prone to mainly supine PCNL in 2 endourologic centers.

Material and methods

We retrospectively analyzed data on 214 consecutive supine PCNLs divided into the first (2011–2013) and last (2014–2016) 3 years of this study. The first 27 cases were also included in a randomized controlled trial (RCT) by comparison with 24 prone PCNLs. We compared the clinical outcome and implementation rate. The surgical team was surveyed for their overall impression of performing supine PCNLs.

Results

The RCT revealed a trend toward shorter operative time (138 vs. 150 minutes), anesthesia time (174 vs. 192 minutes) and hospitalization (2.2 vs. 2.6 days) in the supine PCNL group, without statistical significance and similar stone free rates (SFR) as for the prone PCNL group. Implementation of the supine PCNL reached 96% in 3 years. There was a decrease in operative time (110 vs. 154 minutes; P <0.0001), hospital stay (1.5 vs. 2.1 days; P <0.01), blood transfusion (5% vs. 14%; P <0.05) and rate of ancillary procedures (5% vs. 16%; P <0.05) in the last 3 years of the study. SFR remained stable. Both the surgeons and anesthesiologists expressed their unanimous preference for the supine position over the prone position.

Conclusions

Supine PCNLs are easy to implement without a significant learning curve for an experienced endourologist. They can be employed in complex cases and improve surgeon's ergonomics and anesthesiologist's access to the patient.

Sulfadiazine-Induced Obstructive Nephropathy Presenting with Upper Urinary Tract Extravasation

Background: Obstructive nephropathy is an uncommon side effect of sulfadiazine, which is used for the treatment of toxoplasmosis. We present a case of acute renal colic and urine extravasation of a patient shortly after she was started on this medication. Case Presentation: A 31-year-old female presented with acute renal colic 2 weeks after starting treatment with sulfadiazine and pyrimethamine for ocular toxoplasmosis. Results: A noncontrast computed tomography revealed left hydronephrosis and fluid located around the kidney and in the left gutter. There were no urinary stones. Administration of intravenous contrast revealed significant urine extravasation at the level of the ureteropelvic junction. Intravenous contrast injection confirmed that the extravasation consisted of urine leakage at the ureteropelvic junction. Her clinical condition improved with the insertion of an internal stent, which was left in place for 4 weeks. A retrograde pyelography performed at the time of the internal stent removal ruled out persistent extravasation and filling defects in the left upper urinary tract. Considering the clinical circumstances and the imaging results, it appears that this is a first reported case of sulfadiazine-induced obstructive uropathy associated with urine extravasation. Conclusion: Although rare, obstructive uropathy related to sulfadiazine medication should be promptly suspected, diagnosed, and treated. Patients should be instructed to substantially increase their liquid intake while on that medication.

MRI-transrectal ultrasound cognitive fusion-targeted transperineal template-guided saturation prostate biopsies in a consecutive cohort of men

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Background: MRI of the prostate may improve diagnostic accuracy of prostate cancer. Different fusion approaches with transrectal ultrasound images are employed. Objective: To determine the detection rate of prostate cancer in men undergoing transperineal template-guided saturation biopsy (TTSB) with MRI-based cognitive fusion. Methods: Between the years 2010-2015, 164 consecutive men underwent a multiple-core prostate TTSB. Univariable and multivariable logistic regression analyses were used to address the relationship between clinical TTSB parameters and prostate cancer detection rate. Covariates consisted of age, prostate-specific antigen (PSA), prostate volume, PSA density, digital rectal examination findings, existence of suspicious prostate lesions on MRI, number of previous negative biopsy sets, and number of cores taken during TTSB. Results: Mean age was 65 years and mean PSA was 14 ng/ml, mean prostate volume was 63 ml. Seventy percent of patients had at least two previous negative transrectal biopsy series and another 19% had at least one negative biopsy. One-hundred and fourteen patients (70%) underwent prostate MRI prior to the biopsy. The detection rate of prostate cancer among these patients was 46% of which 69% had Gleason score ≥ 7. Men with a suspicious lesion on MRI (n=80) had a detection rate of 50%, compared to 33% in patients with negative MRI study. On multivariate analysis, the most significant independent predictive factor was PSA density (p= 0.001). Other nearly significant parameters were suspicious MRI lesion, prostate volume and suspicious digital examination. Of note, the prostate cancer detection rate among patients with no MRI study prior to TTSB was 26%. Conclusions: Utilizing MRI cognitive fusion approach increases the detection rate of clinically significant prostate cancer (Gleason score ≥ 7). In patients with existing suspicion for prostate cancer after multiple negative standard TRUS-guided biopsies, performing TTSB after taking into consideration the findings on MRI and PSA density will increase dramatically the detection rate of significant disease.

[Position statement for the diagnosis and treatment of men with benign prostate enlargement and lower urinary tract symptoms]

Benign prostate enlargement causing lower urinary symptoms is a common progressive phenomenon in adult men. Lower urinary tract symptoms may emerge during the storage, voiding, and post micturition phases, harm quality of life and may be caused by a variety of factors. The purpose of evaluation is to identify benign prostate enlargement and factors other than enlarged prostate as the cause of symptoms, and recognize the risk factors for progression of the condition. The goal of treatment is to alleviate symptoms and improve quality of life, and to prevent deterioration of symptoms and development of complications. Medical therapy is the basic approach, whereas surgery and minimally invasive procedures are reserved for patients not interested in medical therapy or for those in whom symptoms were not alleviated by means of medical therapy. In the present position statement, we present the approach to the evaluation and treatment of lower urinary tract symptoms in men with benign prostate enlargement.

High detection rate of significant prostate tumours in anterior zones using transperineal ultrasound-guided template saturation biopsy

Study Type - Diagnostic (exploratory cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Men with persistent suspicion for prostate cancer after previous negative standard transrectal biopsy series are offered saturation biopsy either transrectally or transperineally to increase cancer detection rate. A high-risk group of men with at least two previous negative transrectal biopsies underwent transperineal template-guided saturation biopsy. Prostate cancer was detected in 26%, predominantly in the anterior zones. PSA velocity or doubling time were the most powerful factors to predict cancer.

OBJECTIVE

To evaluate the detection rate and the regional location of prostate cancer in men undergoing transperineal template-guided saturation biopsy (TTSB).

PATIENTS AND METHODS

In all, 92 consecutive men with at least two previous negative transrectal biopsy series who underwent a multiple-core prostate TTSB at our centre were included in the study. • Univariable and multivariable logistic regression analyses were used to address the relationship between parameters before TTSB and prostate cancer-detection rate. • Covariates consisted of age at biopsy, free and total prostate-specific antigen (PSA), prostate volume, digital rectal examination findings, histological findings on previous biopsy, PSA velocity (PSAV), PSA-doubling time (PSADT) and the number of previous negative biopsy sets.

RESULTS

Prostate cancer was diagnosed in 26% of the men. • A median of 30 cores was taken by TTSB. • Adenocarcinoma in >2 cores was detected in 58.5% and Gleason score ≥7 was detected in 46% of the diagnosed men. • Most of the tumours (83.3%) were found in the anterior zones of the gland, with a significantly higher number of positive cores vs the posterior zones (mean 4.9 vs 1.5, P= 0.015). • PSADT and PSAV were the only independent predictors of prostate cancer detection at multivariate analyses with odds ratios of 0.71 (P= 0.014) and 1.58 (P= 0.025), respectively.

CONCLUSIONS

TTSB has a high prostate cancer-detection rate, especially in the anterior zones. • Men after at least two previous negative transrectal biopsy series and persistent suspicion of prostate cancer, as evidenced by rapid PSA dynamics, should be offered TTSB.

The role of brachytherapy in the 21st century for prostate cancer

Men presenting with clinically confined prostate cancer have a variety of established treatment options, among them brachytherapy is gaining increased acceptance, even in the absence of randomized comparative data between brachytherapy, surgery and external radiotherapy. This review summarizes the results of low dose rate transrectal-guided transperineal permanent seed implantation brachytherapy. We present the evolution of the different treatment planning techniques and a comprehensive review of published mature data on 10-year or longer of biochemical and survival outcome for brachytherapy alone, and brachytherapy combined with supplemental external beam radiation therapy with emphasis on its impact on quality of life.

Tubeless percutaneous nephrolithotomy: first 200 cases in Israel

BACKGROUND

Tubeless percutaneous nephrolithotomy is defined as PCNL without postoperative nephrostomy tubes. It is reported to reduce postoperative pain, hospital stay and recovery time. To date the procedure has been reserved for selected patients.

OBJECTIVES

To assess our initial experience in extending the implementation of tubeless PCNL without preoperative patient selection.

METHODS

All consecutive PCNLs performed during 2004-2008 were evaluated. Tubeless PCNL was performed when residual stones, bleeding and extravasation were excluded intraoperatively. Staghorn stones, stone burden, supracostal and multiple accesses, anatomic anomalies, solitary kidneys and operative time were not considered contraindications. We analyzed the clinical data and the choice of tubeless PCNL over time.

RESULTS

Of 281 PCNLs performed during the study period 200 (71%) were tubeless. The patients' average age was 53 years (range 28-82 years), the stone burden was 924 mm2 (400-3150 mm2), operative time was 99 minutes (45-210 min), complication rate was 14% and immediate stone-free rate 91%. There were 81 conversions to standard PCNL (29%) due to expected second-look (n = 47, 58%), impression of bleeding (n = 21,26%), suspected hydrothorax (n = 7, 9%) and extravasation (n = 6, 7%). The transfusion rate was 1%. The median hospital stay was 1 day (1-15 days) and recovery time 7 days (5-20 days). The rate of implementing the tubeless procedure increased steadily along time from 46% to 83% (P = 0.0001).

CONCLUSIONS

Tubeless PCNL can be safely and effectively performed based on intraoperative decisions, without preoperative contraindications. They are easily accommodated by experienced endourologists and provide real advantages.

Detection of prostate specific transcripts in the peripheral blood during brachytherapy predicts postoperative PSA kinetics

BACKGROUND

We evaluated whether detection of prostate-specific antigen (PSA) and human kallikrein 2 (hK2) transcripts in the peripheral blood during brachytherapy could predict biochemical outcome.

METHODS

Eighty-one patients who underwent (125)Iodine-based brachytherapy for localized prostate cancer (Gleason score <8, PSA <20 ng/ml, stage <T3), participated in the study. Brachytherapy was given to 35 patients as monotherapy, to 36 in combination with androgen deprivation therapy (ADT), and to 10 in combination with external beam radiation and ADT. Blood samples from 80 patients were available for analysis. Nested RT-PCR means was used to detect mRNA expression of PSA and hK2 in the peripheral blood. Their expression was analyzed before, during and 1 month after brachytherapy. Patients' biochemical outcome (blood PSA levels) during 3 years of follow-up was correlated with the PCR results.

RESULTS

The incidence of PSA and hK2 mRNA expression in the peripheral blood was significantly higher during than before or after the procedure. Patients with concurrent positive PSA and hK2 PCR results during brachytherapy had higher postoperative blood PSA values and a slower decline rate of PSA compared with patients with negative PSA and hK2 PCR results. No correlations were found between pre- and postbrachytherapy PCR results and biochemical outcome. ADT was the only significant factor that affected PSA and hK2 mRNA expression during brachytherapy.

CONCLUSIONS

Our short-term results suggest that detection of PSA and hK2 transcripts in the peripheral blood of prostate cancer patients during brachytherapy could serve as a predictor of biochemical outcome.

[Alpha blockers in use for symptomatic benign prostatic hyperplasia--are all drugs born equal?]

Alpha-adrenergic blockers are an established form of medical treatment for symptomatic benign prostatic hyperplasia (BPH). Several medications of the class are available, each with its own characteristics. The authors attempted to define the differences between the currently available medications (Terazosin, Doxazosin, Alfuzosin, and Tamsulosin), and to present an evidence-based recommendation for choosing the best treatment option. A literature search was conducted, using Medline queries and the references of review papers, in search of pertinent studies. These included controlled studies comparing the results of treatment with alpha blockers to placebo, or direct comparative studies of alpha blockers, and real life practice, community studies of each of the medications. A similar efficacy emerged from the reviewed articles, but with a different adverse events profile. A higher rate of vasodilatatory, cardiovascular side effects (dizziness, fatigue, and hypotension) was observed with terazosin and doxazosin, when compared with the uroselective alfuzosin and tamsulosin. Of the latter two, hypotension was more frequent with alfuzosin, while ejaculatory dysfunction was more frequent with tamsulosin. In conclusion, each of the four medications is a possible treatment option for BPH, but we believe alfuzosin and tamsulosin are the better choice. In light of an identical efficacy, these medications offer better tolerability, and ease of use of a once daily treatment without dose titration. The choice between the two should be tailored to the individual patient, with alfuzosin associated with hypotensive side effects, and tamsulosin causing ejaculatory dysfunction.

Potentiation of 2-methoxyestradiol-induced cytotoxicity by blocking endothelin A receptor in prostate cancer cells

BACKGROUND

2-Methoxyestradiol (2ME2) is an antitumoral and antiangiogenic compound that inhibits hypoxia-inducible factor (HIF)-1, a key regulator of the hypoxic response that promotes tumor progression. HIF-1alpha, the regulated subunit of HIF-1, is overexpressed in premalignant, cancerous and metastatic lesions of prostate. Endothelin (ET)-1 is a HIF target gene and one that plays an important role during prostate bone metastasis via its interaction with endothelin A (ET(A)) receptor. We reasoned that 2ME2 combined with an ET(A) receptor antagonist would induce potent cytotoxic effects in prostate cancer cells.

METHODS

PC-3 and LNCaP cells were grown alone or cocultured with human osteoblasts. The cells were treated with 2ME2, with an ET(A) receptor antagonist (BQ-123) or with combinations of both compounds. The cells were then evaluated for cytotoxicity, HIF-1alpha protein expression and HIF-1 transcriptional activity.

RESULTS

The combination of 2ME2 with BQ-123 induced synergistic cytotoxic effects in prostate cancer cells and in their cocultures with osteoblasts. No synergism was observed when 2ME2 was combined with the ET(B) selective antagonist, BQ-788. These results correlated with inhibition of HIF-1alpha protein expression, HIF-1 transcriptional activity, and PSA mRNA expression.

CONCLUSIONS

The ET(A) receptor antagonist was capable of potentiating the cytotoxic effects of 2ME2 in prostate cancer cells. These effects were apparently mediated through the inhibition of the HIF-1 pathway. Our in vitro data strengthen the rationale for using 2ME2 in combination with ET(A) receptor antagonists for the treatment of metastatic prostate cancer.

Alfuzosin 10 mg once daily for treating benign prostatic hyperplasia: a 3-year experience in real-life practice

OBJECTIVES

To assess the 3-year efficacy and safety of the selective alpha(1)-blocker alfuzosin at 10 mg once daily in men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) in 'real-life practice'. The influence of treatment response on the risk of acute urinary retention (AUR) and BPH-related surgery was also analysed.

PATIENTS AND METHODS

In all, 689 European men (mean age 67.6 years) were enrolled by general practitioners in a 3-year open-label study with alfuzosin at 10 mg once daily. They were asked to complete the International Prostate Symptom Score (IPSS), its eighth question (bother score), and the Danish Prostatic Symptom Score for sexual function (DAN-PSSsex). Efficacy was analysed at the endpoint in the intent-to-treat population. The impact of baseline variables (age, PSA level, IPSS and bother severity) and dynamic variables (IPSS worsening of >or=4 points and bother at the last available assessment under treatment) on the risk of AUR and BPH-related surgery was evaluated.

RESULTS

With alfuzosin, IPSS improved by 6.4 points (-33.4%) from baseline (P < 0.001), reaching >or=3 points and >6 points in 71.3% and 47.2% of men, respectively. There were also significant (P < 0.001) improvements from baseline in nocturia (-0.8, -25.5%), bother score (-1.7, -40.7%) and DAN-PSSsex weighted scores with treatment. Symptom relief was rapid and maintained over 3 years. Overall, 78 men (12.4%) had an IPSS worsening of >or=4 points, 16 (2.6%) had AUR, and 36 (5.7%) required BPH-related surgery. Symptom deterioration during treatment and high baseline PSA values were the best predictors of AUR and BPH-related surgery. Alfuzosin was well tolerated, dizziness being the most frequent adverse event (4.5%) possibly related to vasodilatation. Ejaculatory disorders were uncommon (0.4%). Changes in blood pressure remained marginal, including in men aged >or=65 years and those receiving antihypertensive agents.

CONCLUSION

Alfuzosin administered for 3 years at 10 mg once daily in real-life practice is effective and well tolerated. High PSA values and symptom worsening under treatment appear the best predictors of AUR and BPH-related surgery in the long term. Treatment with alfuzosin might thus help to identify patients at risk of LUTS/BPH progression in order to optimize their management.

The Role of Phosphodiesterase Type 5 Inhibitors in the Management of Premature Ejaculation: A Critical Analysis of Basic Science and Clinical Data

OBJECTIVES

To assess the usefulness of the phosphodiesterase type 5 inhibitors (PDE5-Is) in the treatment of premature ejaculation (PE) and to describe possible mechanisms to explain their effect.

METHODS

A MedLine search was performed for peer-reviewed articles on the role of PDE5-Is in managing PE. No meta-analysis method was used.

RESULTS

Five manuscripts that examined the efficacy of PDE5-Is in the treatment of PE were retrieved. Three studies used sildenafil as monotherapy and two used it in combination with a serotonin selective reuptake inhibitor (SSRI). Three studies demonstrated a beneficial effect of sildenafil in the treatment of PE, as measured by intravaginal ejaculatory latency time (IELT) and by different questionnaires assessing the patients' subjective feelings of ejaculatory control, sexual satisfaction, and anxiety. One study showed the superiority of sildenafil compared to other modalities. Two studies showed that combination therapy of paroxetine and sildenafil was better than paroxetine alone. One study did not demonstrate a beneficial effect of sildenafil in prolonging IELT, but showed that sildenafil improved patients' perception of ejaculatory control. Another study showed that topical anesthetics were better than sildenafil in the treatment of PE but did not use IELT or a validated questionnaire to measure the efficacy of treatment. Several possible mechanisms could explain effectiveness of the PDE5-Is for treatment of PE: centrally, through the effect on the nitric oxide/cyclic guanosine monophosphate pathway; peripherally by causing relaxation of smooth muscle in the vas deferens, seminal vesicles, prostate, and urethra and inhibition of adrenergic transmission; or locally by inducing peripheral analgesia. Another possibility might be prolongation of the duration of erection.

CONCLUSIONS

Encouraging evidence supports the role of PDE5-Is for treating PE. Possible therapeutic mechanisms of action of PDE5-Is are multiple and complex and include central and peripheral effects. A large population, multicenter, randomized, double-blind, placebo-controlled study is needed to elucidate the efficacy of PDE5-Is in the treatment of PE.

Extending the application of tubeless percutaneous nephrolithotomy

OBJECTIVES

Tubeless percutaneous nephrolithotomy (PCNL) has been successfully performed in selected patients. We assessed its applicability for use without imposing preoperative restrictions.

METHODS

The study consisted of a prospective and consecutive series of 126 patients. Tubeless PCNL was performed when perforation, residual stones, and significant bleeding had been intraoperatively excluded by fluoroscopy, nephroscopy, and hemodynamic assessment. Staghorn stones, supracostal and/or multiple access, anatomic anomalies, previously operated kidneys, solitary kidneys, and operative time were not considered contraindications. The demographic, clinical, and intraoperative and postoperative data were statistically analyzed.

RESULTS

Using this protocol, we performed 66 (52%) tubeless and 60 (48%) regular PCNLs. The average patient age (54 years versus 52 years), stone burden (924 versus 1044 mm2), operative time (116 versus 130 minutes), complication rate (9% versus 13%), hemoglobin decrease (1.2 versus 1.1 mg/dL), and immediate stone-free rate (92% versus 90%) were similar for the tubeless and regular PCNL groups, respectively (P >0.05). The reasons for performing standard PCNL were an expected second-look procedure (n = 35, 58%), an impression of active bleeding (n = 16, 27%), significant extravasation (n = 5, 8%), and suspected hydrothorax (n = 4, 7%). The overall transfusion rate was 3%. The average analgesia requirement (pethidine HCL) was 0.4 and 1.2 mg/kg (P <0.01), the median hospital stay was 1 and 4 days (P <0.0001), and the median back-to-work time was 7 and 15 days (P <0.001) for the tubeless and regular PCNL groups, respectively.

CONCLUSIONS

The results of our study have shown that tubeless PCNL can be safely and effectively performed based on intraoperative factors, without preoperative contraindications. Compared with the standard procedure, tubeless PCNL was associated with reduced postoperative pain, hospital stay, and recovery time.

Preimplant Predictive Factors of Urinary Retention After Iodine 125 Prostate Brachytherapy

OBJECTIVES

To assess the rate and predictive factors of urinary retention after iodine 125 brachytherapy for localized prostate cancer.

METHODS

Between 1998 and 2006, 655 patients with localized prostate cancer (T1-2, Gleason score 7 or less) were treated with brachytherapy at our institution. 42% received neoadjuvant hormonotherapy for prostate downsizing or when brachytherapy was combined with external beam radiation (10%). They underwent real-time interactive implantation (79%) or a preplanned technique (21%). Clinical, treatment-related and dosimetric factors were evaluated for catheterization requirement because of urinary retention. All patients received alpha1-blockers before and throughout at least 30 days posttreatment.

RESULTS

Twenty-one (3.2%) patients required catheterization because of urinary retention. Median time to retention onset was 1 day postimplantation. Univariate and multivariate analyses demonstrated that preimplant ultrasound (US)-based prostate volume and preimplant international prostate symptom scores (IPSS) were significant independent predictive factors for urinary retention (odds ratio [OR] = 6.8 and 3.1, 95% CI = 2.3-11.4 and 0.2-5.9, P = 0.02 and P = 0.03, respectively). Eight catheterized patients were successfully relieved from their catheter by nonsurgical means and 13 underwent minimal (channeling) transurethral resection of the prostate (TUR-P) not earlier than 6 months postimplant. Mean volume of resected prostate tissue was 9.9 mL (range 4.5-15). The perioperative and postoperative courses were uneventful. There was no TUR-P-related incontinence.

CONCLUSIONS

Catheterization for acute urinary retention after brachytherapy is an uncommon event. Our data suggest that preimplant US-based prostate volume and IPSS are the strongest predictors for catheterization. Catheterized patients who are refractory to medical therapy can safely undergo a minimal TUR-P.

[Epidemiological characteristics and trends of testicular cancer in Israel 1992-2002]

OBJECTIVES

Numerous publications from Europe and North America show an increase in the incidence of testicular cancer in past years with substantial differences within and among the different countries. This study aimed to evaluate testicular cancer incidence and other epidemiologic characteristics in Israel in recent years.

METHODS

Incidence data was retrieved from the Israeli National Cancer Registry database. Patients with primary testicular cancer diagnosed in the years 1992-2002 were evaluated. For the sample of the year 2002, cross reference and deeper epidemiologic characterization using hospital archives was performed. Incidence rates were calculated according to age standardized, world population based standard. Analysis of variables of age, religion, origin, occupation, risk factors and histological subtypes was performed.

RESULTS

In the period of 11 years, 983 primary testicular cancer cases were diagnosed in Israeli citizens. Among Jewish men the incidence rate rose from 2.16 to 4.23/100000 while in Arabs it rose from 0.2 to 1.89/100000. Within the Jewish population the incidence rate elevation was notably prominent in immigrants from Asia and Africa. Considering the geographic distribution, in the Northern Negev changes in incidence rate were found to be more noticeable. A statistically significant decrease in the disease presentation age was observed. Germ cell testicular tumors are a leading cause of the process with an elevation of 86.2% in incidence rate from 1992 to 2002.

CONCLUSIONS

The incidence of testicular cancer has increased in Israel in recent years. This trend is strongly associated with previously reported data from economically developed countries. It varies between different population groups. No single hypothesis can be put forward to account for the sudden increase in the disease incidence.

Dorsal Vein Injuries Observed During Penile Exploration for Suspected Penile Fracture

INTRODUCTION

Penile fracture is a rare injury, bearing potential impairment of erectile function if not treated. Patients with clinical presentation of a penile fracture commonly undergo early surgical exploration with the intention to repair a tunica albuginea tear.

AIM

We present a group of men who presented with a penile hematoma following trauma to the erect penis. Exploration revealed an intact tunica albuginea and a dorsal vein tear.

METHODS

Eighteen men (mean age 38 years, range 20-55) presented with suspected penile fracture during an 8-year period. One man presented twice. Two of the patients were managed expectantly and the remaining 16 patients underwent 17 immediate surgical explorations. Explorations were performed under general anesthesia, using a circumferential subcoronal incision and degloving of the penile skin. The tunica albuginea of both penile sides as well as the penile urethra were examined for injuries.

MAIN OUTCOME MEASURES

Medical records were retrospectively reviewed for etiology, symptoms, signs of physical examination, and information on findings of surgical exploration. Data on erectile function, medical treatment for erectile dysfunction, and penile curvature were obtained during follow-up.

RESULTS

In nine of the 17 procedures the tunica albuginea was intact and the only pathological finding was a ruptured dorsal vein. One procedure was negative for both tunical and vascular injury. A tunical tear was detected in the remaining seven procedures. At a mean follow-up of 40 months (range 4-91), five patients required medical treatment for erectile dysfunction, including the two who were managed expectantly, two with a tunical tear, and one with a venous tear.

CONCLUSIONS

Dorsal vein tears may mimic penile fracture. Suggestive findings following trauma to the erect penis prompted exploration for suspected tunica albuginea tear. In less than half of the men was the diagnosis of penile fracture established and treated at surgery.

Degloving and realignment--simple repair of isolated penile torsion

OBJECTIVES

To present the results of repairing congenital or acquired penile torsion by means of a simple surgical procedure that does not involve resection of corporeal tissue.

METHODS

Forty-six circumcised patients (mean age 27 months, range 6 to 119) presented with isolated penile torsion of a greater than 30 degree rotation. The surgical technique involved degloving the penile skin to the penoscrotal junction. Residual torsion was corrected using 5-6/0 polyglactin absorbable suture applied to the desired 12-o'clock position of the penile skin adjacent to the glans and to a location counter to the direction of the torsion in the degloved penile skin sleeve. A wedge of loose ventral penile skin was usually resected. The resultant tightening of the skin allowed for proper alignment of the penis and better cosmesis. The rest of the circumferential incision was closed using the same suture material. The success of the procedure was evaluated according to physician and parental satisfaction with the final outcome.

RESULTS

Thirty-seven patients were available for follow-up (mean 31 months, range 8 to 68). Satisfactory results were achieved in 35 (95%) of the 37 patients; the other 2 had residual torsion. Complications were minor and consisted of postoperative fever and a subcutaneous hematoma in 1 patient that resolved with conservative treatment.

CONCLUSIONS

The degloving and realignment procedure is a simple technique that may be applied safely and successfully in most cases of penile torsion.

Holmium Laser Ureteroscopic Treatment of Various Pathologic Features in Pediatrics

OBJECTIVES

To assess the outcome of pediatric patients treated by ureteroscopy for various pathologic findings.

METHODS

A total of 31 children (median age 5 years, range 0.3 to 14) were ureteroscopically treated for ureteropelvic junction obstruction (UPJO) (n = 6, 1 primary and 5 secondary), ureteral strictures (n = 4), and calculi (n = 21). Miniscopes with a holmium laser were used for lithotripsy and ureterotomy.

RESULTS

The average age in the UPJO group was 1.8 years (range 0.3 to 4), the operative time was 40 minutes (range 30 to 50), and the hospitalization was 1.2 days (range 1 to 2). A successful clinical and functional outcome was maintained after an average follow-up of 16 months (range 8 to 30). The 4 cases of ureteral stricture included two located in the middle ureter and two at the ureterovesical junction. No failures had occurred in this group after an average follow-up of 25 months (range 8 to 40). The calculi cases comprised 10 lower ureteral, 2 upper ureteral, and 9 renal stones, with an average stone burden of 11 mm (range 5 to 20). Three patients (14%) underwent preoperative stenting. Two patients (10%) required ureteral orifice dilation. Postoperatively, 4 patients (18%) had a ureteral catheter left in place, 15 (71%) had an internal stent with an externalized string, and 2 (10%) did not require drainage. The average operative time was 39 minutes (range 15 to 90), and the hospitalization was 1 day (range 0.5 to 2). All patients were rendered stone free.

CONCLUSIONS

The results of our study have shown that the ureteroscopic approach in children with UPJO, ureteral strictures, and urinary calculi is safe and highly effective. Routine preoperative stenting and intraoperative ureteral dilation are not necessary. Stents with external strings were well tolerated and easily removed without anesthesia.

[Pediatric endourology]

OBJECTIVE

To assess the outcome of pediatric patients treated by an endourological approach for various urinary tract pathologies.

METHODS AND MATERIALS

Thirty-seven children (median age 5 years, range 0.3-14 years) were endoscopically treated for ureteropelvic junction obstruction (UPJO) (n= 6), ureteral strictures (n=5), upper urinary tract calculi (n=21) and bladder calculi (n = 5).

RESULT

Upper urinary tract calculi were approached by ureteroscopy (n=12), retrograde intrarenal surgery (n=6) and percutaneous nephrolithotomy (n = 3). The average stone burden was 11 mm (range 5-35 mm) and operative time was 40 minutes (range 15-120 minutes). Bladder calculi were treated percutaneously in 3 cases and transurethrally in 2 cases for an average stone burden of 34 mm (range 7-120 mm). The overall stone-free rate after one procedure was 96%. UPJOs were retrogradely approached in an average operative time of 40 minutes (range 30-50 minutes). Successful clinical and functional outcome was maintained after an average follow-up of 15 months (range 6-30 months). The 5 ureteral strictures included 2 located in the middle ureter and 3 at the ureterovesical junction. The success rate in this group was 80% and the average follow-up 24 months (range 6-40 months). The median hospitalization time for the entire series was 1 day (range 0-7 days). There were no intraoperative complications. Three (8%) patients developed post-operative urinary tract infections. Delayed anterior urethral stricture occurred in 1 case. No additional complications occurred after an average follow-up of 11 months (range 4-36 months).

CONCLUSION

Endourology in children is safe and highly effective. It appears that the indications for endourological treatment in children emulate those of adults.

Survivin expression in the ureteral wall of high degree vesicoureteral reflux in children

INTRODUCTION

Survivin is a member of inhibitor of apoptosis protein family which suppresses apoptosis and regulates cell division. Survivin was not found to be expressed in normal differentiated tissues. CD95 is a cell surface receptor, and it is believed to induce cell death in a variety of cells. The goal of this study is to evaluate the survivin and CD95 expression in bladder and uerters of children operated for vesicoureteral reflux (VUR).

MATERIALS AND METHODS

Sixteen paraffine embeded ureteral units of 11 children with vecico ureterl reflux were treated immunohistochemicaly with survivin and CD95. At operation the distal margins of the ureters were send to histologic exam and a full thickness biopsy from the anterior bladder wall including muscle and mucosa were performed. The control was taken from a urologically normal 9 days old baby who died from myocarditis. The sections were stained with the antibody in the regular method and the degree of staining was graded from 0 to 3, by a single uropathologist.

RESULTS

Immunohistochemistry staining with survivin was positive in all ureters. We had 13 high grade (grade 3-5) and 3 low grade (grade 1-2) vesicoureteral reflux. The average survivin degree of staining in the low grade reflux was 1.33 compared to 2.3 (P = 0.019) in the high grade refluxing ureters. The staining of the control sample was graded 1. The average degree of staining was 1.2 in the bladder wall compared to 2.125 in the ureters. CD95 stained mast cells in ureters and bladders.

CONCLUSIONS

Possitive staining of survivin was found in both ureters and urinary bladders of children that underwent surgical repair of vesicoureteral reflux. The degree of survivin staining was significantly higher in the high grade refluxing ureters compared to low grade reflux and to the bladder wall in the same patients.

The homozygous P582S mutation in the oxygen-dependent degradation domain of HIF-1 alpha is associated with increased risk for prostate cancer

BACKGROUND

The heterodimeric transcription factor HIF-1 (hypoxia-inducible factor 1), consisting of a critically regulated HIF-1 alpha subunit and a constitutively expressed HIF-1 beta subunit, is a master regulator of genes involved in adaptation and survival under low-oxygen conditions. Increased levels of HIF-1 activity are associated with increased tumor aggressiveness, therapeutic resistance, and mortality.

METHODS

We studied 402 prostate cancer patients for the presence of the 1772C > T (P582S) and 1790G > A (A588T) mutations within the oxygen-dependent domain of HIF-1 alpha.

RESULTS

Homozygosity for the P582S mutation was fourfold greater among prostate cancer patients compared to controls (OR = 4.10 [C.I. 95% 1.11 < OR < 17.87], P = 0.018). The existence of this mutation in prostate cancer patients was not associated with any of the clinical or pathological characteristics of the disease. No significant differences were found between the frequencies of A588T mutation in prostate cancer patients and controls.

CONCLUSIONS

Our data suggest that homozygous HIF1A P582S mutation confers significant susceptibility to prostate cancer.

Response to Daily 10 Mg Alfuzosin Predicts Acute Urinary Retention and Benign Prostatic Hyperplasia Related Surgery in Men With Lower Urinary Tract Symptoms

PURPOSE

We analyzed the influence of treatment response on the risk of acute urinary retention and benign prostatic hyperplasia related surgery in 5,792 men complaining of lower urinary tract symptoms who were treated for 6 months with the selective alpha1-blocker alfuzosin at 10 mg once daily.

MATERIALS AND METHODS

The influence of dynamic variables (International Prostate Symptom Score change and bother during treatment) and baseline variables (patient age, prior acute urinary retention managed conservatively, prostate specific antigen, International Prostate Symptom Score and bother severity) on the risk of acute urinary retention and benign prostatic hyperplasia related surgery was estimated using the Kaplan-Meier method and log rank test. The associated HR and 95% CI were calculated using Cox proportional hazard models.

RESULTS

During alfuzosin treatment International Prostate Symptom Score improved by 3 or greater and greater than 6 points in 74.8% and 50.3% of men, respectively. In this unselected population, including 3.8% with prior unoperated acute urinary retention, the rate of acute urinary retention and benign prostatic hyperplasia related surgery events during treatment was low (0.5% and 1.1%, respectively). Men with stable or worsening International Prostate Symptom Score were at increased risk for acute urinary retention or surgery (HR 3.75, 95% CI 1.58 to 8.89, p = 0.003 and HR 4.71, 95% CI 2.69 to 8.24, p <0.001, respectively). Prior acute urinary retention was a strong predictor of acute urinary retention relapse and surgery (HR 10.35, 95% CI 4.29 to 26.08, p <0.001 and HR 3.57, 95% CI 1.59 to 7.98, p = 0.002, respectively). Bother score greater than 3 during treatment was the strongest predictor of surgery (HR 7.61, 95% CI 4.16 to 13.93, p <0.001). Prostate specific antigen had much less predictive value.

CONCLUSIONS

This 6-month real life practice study shows that alfuzosin is associated with a low incidence of acute urinary retention and benign prostatic hyperplasia related surgery. It also suggests that responder status is the most important predictor of acute urinary retention and benign prostatic hyperplasia related surgery. Thus, first line treatment with alfuzosin may help select patients at risk for benign prostatic hyperplasia progression to optimize treatment.

Are consecutive nightly recordings required for valid evaluation of sleep-associated erections?

We questioned the need for more than one RigiScan recording for accurate assessment of sleep-associated penile erections and determine the necessity of consecutive nightly recordings for valid evaluation of sleep-associated erections. Men complaining of erectile dysfunction (ED) and referred to RigiScan evaluation for the first time participated. Recordings were performed at the patient's home during two consecutive nights, and data on test time, number of erections, erection duration, minimal and maximal base and tip tumescence and rigidity were retrieved for both nights. Normal erectile function was defined with the recording of at least one erection (70 out of 100% tip rigidity lasting for at least 10 min during either night). The main outcome measures were RigiScan recordings. Group 1 consisted of 29 men (mean age 42.4+/-13.8 years, range 22-71) who had normal erections, all during the first night. Group 2 consisted of 26 men (mean age 48.6+/-13.5 years, range 25-70) who failed to fulfill both criteria for normal erection. In Group 2, only the values for penile base rigidity and erection duration were normal during the first night: the parameters of maximal base tumescence, tip rigidity, number of effective erections and duration of effective erections that were impaired during the first night were significantly worse (P<0.01) during the second night. The required information for the diagnosis of psychogenic ED was obtained during the first night in >50% of the participants. Men with normal erections during the first night can be spared the inconvenience and cost of re-testing. Consecutive night recording should be reserved for patients whose recorded data during the first night did not fulfill the criteria for normal erection.

Mutation screening and association study of the candidate prostate cancer susceptibility genes MSR1, PTEN, and KLF6

BACKGROUND

MSR1, PTEN, and KLF6 have been implicated as candidate susceptibility genes for prostate tumorigenesis.

METHODS

Three hundred Jewish prostate cancer patients were screened for alterations in these genes.

RESULTS

MSR1 was conserved in all patients. PTEN screening revealed a novel missense mutation and a silent change. Five KLF6 alterations were detected in 17 patients, including Q160X, the only nonsense KLF6 germline mutation described to date in a cancer patient. The KLF6 IVS1-27G>A polymorphism, recently associated with prostate cancer risk, was detected in 11.9% of the patients and 17.3% of the controls (P = 0.043). IVS1-27A allele frequency was significantly lower in prostate cancer patients (P = 0.030), specifically in Ashkenazi patients (P = 0.047) compared to controls.

CONCLUSIONS

We found no evidence that MSR1 and PTEN germline mutations are associated with prostate cancer risk in Jews. The negative association between KLF6 IVS1-27A and prostate cancer risk supports a population-specific effect of susceptibility alleles in prostate tumorigenesis.

Sexual dysfunction in women partners of men with erectile dysfunction

We evaluated 113 female partners of men with erectile dysfunction (ED) attending a sexual dysfunction clinic in order to define sexual dysfunction among these women. In all, 51 (45%) women denied having any sexual dysfunction. The other 62 (55%) responded to questions classifying their complaint(s) according to the international classification of female sexual dysfunction (FSD) in the following topics (40/62, 65%, reported having more than one problem): decreased sexual desire (n=35, 56%), sexual aversion (none), arousal (n=23, 37%) and orgasmic disorders (n=39, 63%), dyspareunia (n=19, 31%), vaginismus (n=3, 5%), and noncoital sexual pain (none). Many female partners of men with ED report having some form of sexual disorder, mostly orgasmic problems and decreased sexual desire. Therefore, for optimal outcome of ED treatment, evaluation and treatment of male and FSD should be addressed as one unit within the context of the couple, and be incorporated into one clinic of sexual medicine.