Holmium laser for the surgical treatment of benign prostatic hyperplasia.

INTRODUCTION: Holmium laser ablation of the prostate (HoLAP) is a surgical approach for treatment of benign prostatic hyperplasia (BPH). Limited evidence suggests laser ablation/vaporization is inferior to enucleation with respect to reoperation rates. Our objective was to determine if properly performed laser ablation results in outcomes similar to enucleation. MATERIALS AND METHODS: A total of 198 patients with moderate to severe lower urinary tract symptoms and/or acute urinary retention had holmium laser enucleation of the prostate (HoLEP) or HoLAP between 2008 and 2014. Patients with metastatic prostate cancer, prior pelvic radiation, or bladder cancer involving the bladder neck or prostatic urethra were excluded. All procedures involved residents and were supervised by one experienced surgeon. The decision to perform HoLAP versus HoLEP was made intraoperatively. Demographics, pre, peri and postoperative data were collected. RESULTS: A total of 169 men were analyzed: 54 had HoLAP and 115 had HoLEP. Mean follow up was 27.16 months for HoLAP, and 38.18 months for HoLEP. As expected, the HoLEP group had larger prostates, longer mean operative times, and greater reduction in total PSA. There was no difference in the net change of flow rate between groups. CONCLUSION: Both HoLEP and HoLAP are appropriate surgical interventions for the management of BPH, when properly performed. Our findings suggest that adequate ablation of prostatic adenoma results in similar 2 year outcomes as enucleation.

LUTS in pelvic ischemia: a new concept in voiding dysfunction.

Lower urinary tract symptoms (LUTS) are a group of voiding symptoms affecting both genders as they age. Traditionally, LUTS in men were commonly attributed to bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE). It was later shown that, in approximately one-third to more than one-half of cases, LUTS in men are not associated with BOO. Urodynamic changes in the male bladder and symptom scores in aging men were found to be identical to their age-matched female counterparts. These observations suggested that LUTS in the elderly do not necessarily relate to BOO and may result from local changes in bladder muscle, nerves, and blood vessels. However, aging factors predisposing to bladder dysfunction and LUTS remain unknown. Growing evidence suggests that aging-associated pelvic ischemia may be a primary factor in the development of nonobstructed nonneurogenic overactive bladder and LUTS. First identified in experimental models and later in clinical studies, pelvic ischemia has been shown to compromise the lower urinary tract structure and lead to dysfunction. Structural and functional consequences of bladder and prostate ischemia have been documented in animal models. Clinical studies have shown that bladder and prostate blood flow decreases with aging. The severity of LUTS in elderly patients correlates with the degrees of bladder ischemia. LUTS improvement with α blockers has been associated with increased bladder blood flow. Pelvic ischemia may be an independent factor in nonobstructed nonneurogenic bladder instability and LUTS. Further research into the pathophysiology of LUTS in pelvic ischemia may lead to better management of this problem in the elderly population.

Office-Based HE-TUMT Costs Less than Medication over Four Years in Treating Benign Prostatic Hyperplasia.

OBJECTIVES: Benign prostatic hyperplasia (BPH) can cause lower urinary tract symptoms (LUTS). Medications are first line treatment for mild-moderate BPH. Office-based minimally invasive therapies (MITs) are also acceptable early treatment options but comparisons of MIT to medications are limited. MIT may be equally effective and less costly compared to long-term medical therapy. We compared data from a medication trial to pooled data of high-energy transurethral microwave therapy (HE-TUMT) to evaluate differences in outcomes and costs between the modalities. STUDY DESIGN: Covariate-adjusted comparison of treatments from independent clinical trials. MATERIALS AND METHODS: Data from Medical Therapy of Prostatic Symptoms (MTOPS) study arms were compared to Urologix pooled data from seven HE-TUMT studies at 25 centers. Improvements in voiding symptoms and quality of life (QoL) were determined and a repeated measure logistic regression analysis to control for baseline covariates was performed. Cost data were collected using published outcomes, Medicare 2013 national averages, and discount online pharmacy prices. RESULTS: HE-TUMT provided significant improvement in voiding symptoms and QoL compared to all MTOPS arms through two years. At four years, all therapies maintain similar improvements when adjusting for baseline covariates. Four year cumulative costs of HE-TUMT ($3,620) were less than combination medical therapy ($7,200). CONCLUSIONS: HE-TUMT provides better improvement of LUTS compared to medication for two years. At four years, all therapies provide comparable improvement but HE-TUMT is less expensive with better QoL. This suggests that HE-TUMT is an excellent alternative to medical therapy that should be routinely discussed and offered during detailed management of BPH.

Structural modifications of the prostate in hypoxia, oxidative stress, and chronic ischemia.

PURPOSE: Clinical studies have reported a correlation between pelvic ischemia and voiding dysfunction in elderly men. The aim of this study was to identify and compare prostate structural modifications in cultured cells and in a rabbit model after exposure to hypoxia, oxidative stress, and chronic ischemia. MATERIALS AND METHODS: Cultured human prostate smooth muscle cells (SMCs), epithelial cells (ECs), and stromal cells (SCs) were incubated under normoxia, hypoxia, and oxidative stress conditions by use of a computerized oxycycler system. We developed a rabbit model of chronic prostate ischemia by creating aorto-iliac arterial atherosclerosis. Markers of oxidative stress were examined by using fluorometric analysis and enzyme immunoassay. Prostate structure was examined by using Masson's trichrome staining and transmission electron microscopy (TEM). RESULTS: Lipid peroxidation was found in SMCs exposed to hypoxia and in all cell types exposed to oxidative stress. We identified protein oxidation in ECs exposed to hypoxia and in all cell types exposed to oxidative stress. Markers indicating oxidative damage were present in chronically ischemic rabbit prostate tissue. These reactions were associated with DNA damage. Prostate ischemia resulted in epithelial atrophy, loss of smooth muscle, and diffuse fibrosis. TEM showed swollen mitochondria with degraded cristae, loss of membrane, loss of Golgi bodies, degenerated nerves, and disrupted cell-to-cell junctions. CONCLUSIONS: Human prostate cells exhibited differential reactions to hypoxia and oxidative stress with widespread DNA damage. Structural modifications in ischemic prostate tissue were similar to those in cells exposed to oxidative stress. Structural changes due to ischemia and oxidative stress may contribute to prostatic noncompliance in aging men.

Could nocturia be an indicator of an undiagnosed sleep disorder in male veterans?

OBJECTIVE: To determine if men presenting with nocturia and/or voiding complaints may have undiagnosed symptoms of sleep-disordered breathing (SDB). MATERIALS AND METHODS: We conducted a cross-sectional study with men presenting to the Veterans Administration Boston Healthcare System Urology clinic between August 2012 and January 2013. Patients were asked to complete the American Urological Association symptom score and the Berlin sleep questionnaire to evaluate their voiding complaints and sleep quality. We performed univariable and multivariable statistical analyses to identify correlations between a positive Berlin score and voiding symptoms, with an emphasis on nocturia. RESULTS: A total 618 completed questionnaires were included. More than 65% of patients reported nocturia. Of those reporting nocturia, 55% also had a positive Berlin score. The American Urological Association symptom score components of frequency and nocturia, as well as body mass index and hypertension, were shown to be significant independent predictors of a positive Berlin questionnaire, suggesting high likelihood of SDB. Conversely, a positive Berlin questionnaire was a significant independent predictor of nocturia, suggesting high degree of correlation between the 2 conditions. CONCLUSION: Nocturia and other voiding symptoms, such as frequency, predict a positive Berlin score, and vice versa. Patients with a positive Berlin score may have an undiagnosed sleep disorder, the sequelae of which can lead to significant health consequences. If present, treatment of SDB can ameliorate voiding symptoms. Urologists should consider administration of the Berlin score in their office, particularly in patients refractory to treatment for their voiding complaints, and if positive, consider referral to a sleep specialist.

Comparing the life concerns of prescription opioid and heroin users.

This study explored life concerns of prescription opioid (PO) and heroin users. Persons entering opioid detoxification rated their level of concern about 43 health and welfare items. Using exploratory factor analysis and conceptual rationale, we identified ten areas of concern. Participants (N=529) were 69.9% male, 87.5% non-Hispanic Caucasian, and 24.2% PO users. Concern about drug problems was perceived as the most serious concern, followed by money problems, relationship problems, mental health, and cigarette smoking. PO users expressed significantly lower concern about drug problems (p=.017) and transmissible diseases (p<.001), but were more concerned about alcohol use (p<.001) than heroin users. There were no significant differences with regard to the other 7 areas of concern. Recognition of the daily worries of opioid dependent persons could allow providers to better tailor their services to the context of their patients' lives.

Willingness to use HIV pre-exposure prophylaxis among opiate users.

Few studies of pre-exposure prophylaxis (PrEP) to prevent HIV infection have focused on drug users. Between February to September 2013, we asked 351 opiate injectors entering detoxification treatment about HIV risk, knowledge about PrEP, and willingness to use a once daily PrEP pill under one of two randomly assigned effectiveness scenarios-40 % (low) or 90 % (high) effective in reducing HIV risk. Participants were 70 % male and 87 % non-Hispanic White. Only 7 % had heard of a drug to reduce HIV risk, yet once informed, 47 % would be willing to take such a pill [35 % of those in the low effectiveness scenario and 58 % in the high group (p < 0.001)]. Higher perceived HIV risk was associated with greater willingness to take medication. Increasing knowledge of PrEP and the rate of HIV reduction-effectiveness promised will influence its use among targeted high-risk drug users.

Limited spending: an analysis of correctional expenditures on antiretrovirals for HIV-infected prisoners.

OBJECTIVE: Correctional facilities provide a critical opportunity to treat and manage human immunodeficiency virus (HIV) and HIV-related complications among inmates. Inmates bear a higher HIV burden than the general population, and many have never received HIV care prior to incarceration. The standard of care in the community and in corrections for the treatment of HIV is highly active antiretroviral therapy (HAART). This study evaluated U.S. correctional expenditures for antiretrovirals (ARVs) and compared them to the estimated need for ARVs among HIV-infected prisoners in the U.S. to treat this population successfully. METHODS: The total number of HIV-infected prisoners in the United States was estimated using Bureau of Justice Statistics data. The National Sales Perspectives Audit, Combined Retail and Nonretail, July 1999 to December 2004 was used to estimate correctional ARV expenditures in 2004. Both measures were used to calculate treatment costs for ARV therapy. RESULTS: The analysis demonstrates that, in 2004, total ARV sales represented only 29% of the total necessary to treat all HAART eligible inmates with known HIV infection. CONCLUSION: There is a substantial unmet need for ARVs in correctional health care. Although many barriers exist to treating all eligible HIV-infected prisoners, treatment reduces costs associated with HIV-related complications and may encourage linkage to HIV care in the community. Treatment of all eligible HIV-infected inmates should be a public health priority.

Linkage to methadone treatment from acute opiate detoxification treatment.

Methadone maintenance treatment (MMT) is a safe pharmacological treatment strategy for addiction to heroin and other opiates; however, linking individuals to MMT is often challenging. We present results from a pilot project (Project VISTA)funded by the Center for Substance Abuse Treatment that helps heroin-dependent injection drug users (IDUs) transition from acute heroin detoxification to MMT. Participants are referred to Project VISTA by the state detoxification center, and Project VISTA facilitates entry into an MMT program, providing full financial support for up to 24 weeks. In addition, Project VISTA provides case management and referral to ancillary services such as housing, other medical care, and mental health treatment. From May 2005 to May 2006, 60 individuals were enrolled in Project VISTA. A total of 41 participants., (69.5 percent) remained in treatment for at least 24 weeks, with a mean number of weeks in treatment of 31. A Kaplan-Meier analysis was performed on all participants, and the incidence of individuals being discharged from treatment was 2 percent per week. Project VISTA, in cooperation with the state detoxification center and a Providence-based MMT program, has created a model that provides continuity of treatment services to high-risk, HIV-negative IDUs. Our model demonstrates that through facilitating the transition from an opiate detoxification program into an MMT program, individuals with chronic heroin addiction can successfully access and engage in treatment.