Potential benefit of transrectal saturation prostate biopsy as an initial biopsy strategy: decreased likelihood of finding significant cancer on future biopsy.

OBJECTIVE: To identify the ability of transrectal saturation prostate biopsy (SPBx) as the initial diagnostic approach to reduce the likelihood of finding previously unrecognized prostate cancer (PCa) during repeat prostate biopsy. MATERIALS AND METHODS: We reviewed PCa detection in 561 men who underwent first repeat SPBx after initial negative biopsy between March 2002 and April 2012. We divided the patients on the basis of the number of cores retrieved on initial biopsy (group 1, initial negative SPBx [n = 81] and group 2, initial negative extended prostate biopsy [n = 480]). The yield of repeat SPBx was compared between the 2 groups. Insignificant PCa and low-risk PCa were defined according to Epstein criteria and D'Amico risk criteria, respectively. RESULTS: PCa detection on first repeat SPBx was 43.1% lower in group 1 (19.8% vs 34.8%; P = .008). Moreover, lower rate of significant PCa (31.3% vs 74.3%; P <.001) and intermediate- and/or high-risk PCa (25.0% vs 50.9%; P = .048) in group 1. Multivariate analysis confirmed that initial negative SPBx decreased PCa detection on first repeat SPBx (odds ratio = 0.41, 95% confidence interval 0.22-0.78). CONCLUSION: Men whose initial biopsy was per transrectal saturation technique were less likely to have cancer identified during repeat biopsy. Furthermore, PCa diagnosed after negative initial SPBx was much more likely to be clinically insignificant. These findings suggest that SPBx may be less likely to miss clinically significant cancer during initial prostate biopsy. If confirmed in other studies, this suggests that initial biopsy by saturation technique may eliminate the need for most men to undergo repeat biopsy.

Vacuum erection devices to treat erectile dysfunction and early penile rehabilitation following radical prostatectomy.

Vacuum erection devices (VED) are becoming first-line therapies for erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, phosphodiesterase-5 inhibitors have limited efficacy in elderly patients or patients with moderate to severe diabetes, hypertension, and coronary artery disease. Alternative therapies, such as VED, have emerged as a primary option for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of post-radical prostatectomy venoocclusive dysfunction. This is evident by the preservation of penile length and girth seen with the early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size before implantation of the penile prosthesis.

The clinical utility of atypical cytology is significantly increased in both screening and monitoring for bladder cancer when indexed with nuclear matrix protein-22.

OBJECTIVES: To assess atypical cytology as a positive bladder tumour marker and to determine if indexing atypical cytology to nuclear matrix protein-22 (NMP22) can decrease the false-positive results or increase the positive predictive value (PPV). PATIENTS AND METHODS: In all, 197 patients at risk of bladder cancer were identified as having atypical urine cytology; 126 were incident (screening) cases and 71 were prevalent (monitoring) cases of bladder cancer. All patients with atypical cytology were evaluated using office cystoscopy. All cancers were confirmed histologically and patients had a negative upper tract study within a 1-year interval. The atypical cytology was then indexed with NMP22 values in an effort to decrease the false-positive results. RESULTS: Atypical cytology detected 17 cancers in the 126 patients who were screened, giving a PPV of 13% (17/126). When stratified by NMP22, using a threshold of >10 U/mL, the PPV increased to 71% (15/21). In the 71 patients who were being monitored, atypical cytology detected 43 cancers, for a PPV of 61% (43/71). When stratified by NMP22 using a threshold of >6 U/mL, the PPV increased to 92% (35/38). CONCLUSIONS: The clinical utility of atypical cytology was significantly increased in both screening and monitoring for bladder cancer when indexed with NMP22 levels.

Saturation technique does not decrease cancer detection during followup after initial prostate biopsy.

PURPOSE: It has been reported that the prostate cancer detection rate in men with prostate specific antigen 2.5 ng/ml or greater undergoing saturation (20 cores or greater) prostate biopsy as an initial strategy is not higher than that in men who undergo 10 to 12 core prostate biopsy. At a median followup of 3.2 years we report the cancer detection rate on subsequent prostate biopsy in men who underwent initial saturation prostate biopsy. MATERIALS AND METHODS: Saturation prostate biopsy was used as an initial biopsy strategy in 257 men between January 2002 and April 2006. Cancer was initially detected in 43% of the patients who underwent saturation prostate biopsy. In the 147 men with negative initial saturation prostate biopsy followup including digital rectal examination and repeat prostate specific antigen measurement was recommended at least annually. Persistently increased prostate specific antigen or an increase in prostate specific antigen was seen as an indication for repeat saturation prostate biopsy. RESULTS: During the median followup of 3.2 years after negative initial saturation prostate biopsy 121 men (82%) underwent subsequent evaluation with prostate specific antigen and digital rectal examination. Median prostate specific antigen remained 4.0 ng/ml or greater in 57% of the men and it increased by 1 ng/ml or greater in 23%. Cancer was detected in 14 of 59 men (24%) undergoing repeat prostate biopsy for persistent clinical suspicion of prostate cancer. No significant association was demonstrated between cancer detection and initial or followup prostate specific antigen, or findings of atypia and high grade prostatic intraepithelial neoplasia on initial saturation prostate biopsy. Cancers detected on repeat prostate biopsy were more likely to be Gleason 6 and organ confined at prostatectomy than were those diagnosed on initial saturation prostate biopsy. CONCLUSIONS: Previous experience suggests that, while office based saturation prostate biopsy improves cancer detection in men who have previously undergone a negative prostate biopsy, it does not improve cancer detection as an initial biopsy technique. We now report that the false-negative rate on subsequent prostate biopsy after initial saturation prostate biopsy is equivalent to that following traditional prostate biopsy. These data provide further evidence against saturation prostate biopsy as an initial strategy.

Nerve-sparing surgery significantly affects long-term continence after radical prostatectomy.

OBJECTIVES: In this long-term prospective study we evaluated the factors affecting urinary continence after radical prostatectomy. METHODS: In this study, we recruited 156 patients (mean age, 64.1 +/- 6.7 years; follow-up, 7.8 +/- 1.3 years; prostate-specific antigen [PSA] level, 9.57 +/- 8.81 ng/mL) who underwent radical prostatectomy between 1995 and 1998. Long-term data were obtained on 152 patients, with 4 patients lost to follow-up. Incontinence was evaluated by the number of pads per day. Follow-up data were collected at 3, 6, 12, and 24 months and annually. The multivariate analysis included the following variables: preoperative PSA levels, nerve-sparing (NS) status (bilateral NS, unilateral NS, and non-NS), and age at the time of operation (< or = 65 or > 65 years). RESULTS: With a mean follow-up of 7.8 +/- 1.3 years, the overall incontinence rate was 17.7% (27 of 152). The incontinence rates were significantly higher in the non-NS group (18 of 61) compared with the bilateral NS group (6 of 66; P <0.05). No significant difference was seen between the unilateral NS and non-NS groups in terms of incontinence rates (P >0.05). When stratified by the NS status, the bilateral NS group had a significant improvement in overall continence. The association between age and incontinence was significant: P <0.05 for patients 65 years or younger (7 of 85) versus those older than 65 years (20 of 67). The association between the preoperative PSA levels and incontinence was not significant but showed a trend (the median PSA in the incontinence group was 8.75 ng/mL; in the continence group it was 5.9 ng/mL; P = 0.0534). CONCLUSIONS: Nerve-sparing radical prostatectomy improves the time interval to regain continence and long-term continence rates.

Female sexual dysfunction: classification, pathophysiology, and management.

Female sexual dysfunction is a prevalent problem in the general community; however, it has not been studied as extensively as male sexual dysfunction. Female sexual dysfunction is a common complication after most pelvic surgeries. With the introduction of screening programs, most pelvic malignancies are detected at earlier stages and in younger patients. Sexual dysfunction is a major quality-of-life issue in these young women. Hysterectomy (simple or radical) is the most common type of pelvic surgery in women and is one of the most important causes of female sexual dysfunction. Additionally, female sexual dysfunction is an important issue after urologic (radical cystectomy) and colorectal surgeries (simple and radical proctocolectomy). Sexual dysfunction is a common problem among postmenopausal women. Modifications in the surgical technique (nerve sparing) are rapidly evolving in the field of urology and colorectal surgery, which will be soon followed by modifications in the field of gynecologic surgery. In this article we summarize the pathophysiology and classification of female sexual dysfunction, with special emphasis on the relationship between female sexual dysfunction and pelvic surgeries.

Penile rehabilitation following radical prostatectomy: role of early intervention and chronic therapy.

The increase in the number of prostate cancer survivors and their relatively young age has prompted many urologists to concentrate on early penile rehabilitation to improve potency rates following radical prostatectomy. Positive results from various procedures range from 14% to 81% following bilateral nerve-sparing laparoscopic radical prostatectomy, to 43% to 97% following robotic-assisted laparoscopic prostatectomy. An early program with an erectaid improves erectile physiology and performance and logistically, the combination of a 5-phosphodiesterase inhibitor and a vacuum constriction device may prove to be the most user-friendly, cost-effective, and patient-compliant. Other issues that affect patient compliance, such as loss of interest and fear of undertaking sexual activity, will only be revealed through long-term patient follow-up and care.

The early use of transurethral alprostadil after radical prostatectomy potentially facilitates an earlier return of erectile function and successful sexual activity.

OBJECTIVE: To assess whether early introduction of the Medicated Urethral System for Erection (MUSE(TM), Vivus Inc., Mountain View, CA, USA) after radical prostatectomy (RP) results in a shorter recovery time for the return to functional erections and successful sexual activity. PATIENTS AND METHODS: In a prospective study of 91 sexually active men who had a nerve-sparing RP for prostate cancer, 56 were treated with MUSE (125 or 250 microg three times per week for 6 months) while the remaining 35 had no erectogenic aids, except as necessary when attempting sexual activity. Self-administration of MUSE was initiated approximately 3 weeks after RP. Treatment efficacy was analysed by the patient's response to the Sexual Health Inventory for Men (SHIM) questionnaire. RESULTS: The mean patient age was approximately 59 years and the median follow-up 6 months; the compliance rate was 68%. Patients reported a significant improvement in all domains of the SHIM questionnaire after using MUSE. At the end of 6 months 74% of the patients who remained on MUSE were able to have successful vaginal intercourse. Of patients who completed the 6-month course of MUSE, half were able to have successful vaginal intercourse by the end of treatment. Most of these patients reported the recovery of spontaneous erections and required no additional erectogenic aids for successful intercourse. They had a mean SHIM score of 18.9. All 56 patients who received MUSE reported mild penile aching or urethral burning, and of these, 32% discontinued treatment. In the untreated control group, 37% regained erections sufficient for vaginal intercourse at the 6-month follow-up, with a mean SHIM score of 15.8. Of the control patients who recovered penile function, 71% were dissatisfied with the quality of their erections and sought adjuvant therapy. CONCLUSIONS: Initiating MUSE shortly after RP is safe and tolerable, and appears to shorten the recovery time to reagin erectile function.

The incidence of high-grade prostatic intraepithelial neoplasia and atypical glands suspicious for carcinoma on first-time saturation needle biopsy, and the subsequent risk of cancer.

OBJECTIVE: To investigate the detection rate and extent of high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical glands (AG) suspicious for prostate cancer, and the cancer risk in subsequent biopsies, diagnosed by a first 24-core saturation biopsy, as although the optimum extent of biopsy is controversial there is a trend to increase the number of cores taken, and apart from detecting prostate cancer, identifying HGPIN and AG is associated with a greater risk of finding cancer in subsequent biopsies, thus warranting a closer follow-up. PATIENTS AND METHODS: The study included 100 men with consecutive first-time saturation biopsies; the indications for biopsy were an abnormal digital rectal examination and/or a serum prostate-specific antigen (PSA) level of >2.5 ng/mL. Each biopsy specimen was reviewed retrospectively by two pathologists to confirm the histological diagnosis. The number and percentage of cores positive for HGPIN, bilateral involvement and multifocality (HGPIN involving two or more cores) were recorded in each case. The presence of AG and cancer was also recorded. An extended (10-12 cores) repeat biopsy was available in 23 patients. RESULTS: The median (range) age and PSA level of the patients was 63 (41-80) years and 4.9 (1.5-67.0) ng/mL, respectively. Of the 100 patients, 34% had normal findings (benign prostatic tissue, BPT), 39% had cancer, 26% had HGPIN and cancer, 22% had HGPIN alone, and 5% had AG. Repeat biopsies were available in nine of the 22 (41%) patients with HGPIN, four of five with AG, and 10 of the 34 (29%) with BPT. The median (range) interval between the first and second biopsy was 13 (4-36) months. Prostate cancer was detected at the second biopsy in a third of patients with isolated HGPIN on the first biopsy, and one of the four with AG. None of the patients with BPT had cancer on re-biopsy. The cancer detection rate was significantly greater in patients with multifocal than in those with unifocal HGPIN (80% vs none, P = 0.010). The median number of cores and percentage of tissue involved by HGPIN was 3.5 (2-5) and 1.0 (0.5-1.2)%, respectively, in patients with cancer detected in repeat biopsies, compared to 1.0 (1-3) and 0.2 (0.2-0.6)% in patients without cancer on repeat biopsy (P = 0.023 and 0.015, respectively). CONCLUSION: Identifying multifocal HGPIN on first saturation biopsy is associated with an overall cancer detection rate of 80% on repeat 10-12-core biopsy. Although there were few patients, the detection of multifocal HGPIN warrants additional searches for concurrent invasive carcinoma by repeated biopsy.

Treatment of erectile dysfunction: update.

Erectile dysfunction (ED) is the inability to achieve and maintain an erection. Erectile function is dependent upon complex interactions of neural and vascular pathways. A major neurotransmitter that facilitates erectile function is nitric oxide. Treatment of ED has expanded to include effective oral agents. Previous ED treatments have consisted of intracavernosal injection, transurethral dilators, and vascular constriction devices. Clinical management of ED will be presented with some discussion on the prostatectomy client.

Outcomes in patients with urothelial carcinoma of the bladder with limited pelvic lymph node dissection.

OBJECTIVES: To evaluate the rates of local and systemic progression (LP and SP), recurrence-free survival and overall survival for patients with urothelial carcinoma of the bladder with limited pelvic lymph node dissection (PLND) in 1987-2000. PATIENTS AND METHODS: A consecutive series was analysed of 385 patients (median age 61.9 years, range 30.7-83.8) treated by limited bilateral PLND and radical cystectomy (RC) between 1987 and 2000, with negative surgical margins on final pathology. All patients were staged N0M0 before RC, and none received neoadjuvant radiotherapy or chemotherapy. The boundaries of the limited PLND were the pelvic side-wall between the genitofemoral and obturator nerves, and bifurcation of iliac vessels to the circumflex iliac vein. LP was defined as a radiographic soft-tissue density of > or = 2 cm below the bifurcation of the aorta. Pathological characteristics, based on the 1997 Tumour-Nodes-Metastasis system, recurrence patterns, and recurrence-free and overall survival, were determined. RESULTS The median (range) overall follow-up was 45.1 (1.1-165.6) months; the number of lymph nodes (LNs) reported per patient was 12 (2-32). Of the 385 patients, 130 (33.8%) had evidence of LP and 60 (15.6%) of SP. The 5-year recurrence-free and overall survival rates were both 71% for patients with organ-confined, N0 tumours, and 23% and 26% for unconfined, N0 tumours. Positive LNs were found in 45 (12%) patients, who had a recurrence-free and overall survival rate of 9% at 5 years. CONCLUSION: Compared with published reports of similar cohorts of patients managed with RC and extended PLND, the present study suggests that limited PLND is associated with suboptimal staging, greater rates of LP, and lower rates of recurrence-free survival, particularly for patients with unconfined or LN-positive disease.

Erectile dysfunction following radical retropubic prostatectomy: epidemiology, pathophysiology and pharmacological management.

Radical prostatectomy has been the time-honoured and standard treatment option for prostate cancer. Erectile dysfunction (ED) is one of the common quality-of-life issues following radical prostatectomy. The recovery of potency following radical prostatectomy varies from 16% to 86%. Although major modifications in surgical technique appear to be promising, the reported ED rates are still high. The time period required for the recovery of erectile function after surgery varies from 6 to 24 months. During this period of neuropraxia lack of natural erections produces cavernosal hypoxia. This cavernosal hypoxia has been implicated as one of the most important factors in the pathophysiology of ED. Cavernosal hypoxia predisposes to cavernosal fibrosis, ultimately producing venous leak and long-term ED. Interruption of this cascade of events has been the major challenge for physicians. Physicians have several options available for the treatment of ED. However, oral treatment options have quickly become established as first-line treatment options. Sildenafil has been most extensively studied in the radical prostatectomy population. In patients who do not respond to oral therapy alone, standard treatment options (intracavernosal injections, vacuum constriction devices and intraurethral alprostadil) are useful. Use of penile prostheses is one of the oldest treatment options available for the treatment of ED but is used only as a last resort. Initial attempts to promote the earlier recovery of erectile function appear to be promising. However, further confirmatory studies are essential. The roles of gene transfer and growth factors are still in experimental stages. In this review we discuss the epidemiology, pathophysiology and treatment options available for ED following radical prostatectomy.

Saturation technique does not improve cancer detection as an initial prostate biopsy strategy.

PURPOSE: We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy. MATERIALS AND METHODS: Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies. RESULTS: Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group. CONCLUSIONS: Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.

Neurovascular preservation in female orthotopic radical cystectomy significantly improves sexual function.

Radical cystectomy has emerged as a standard treatment option for patients with muscle invasive bladder cancer. The impact of nerve-sparing cystectomy with urethra and vaginal sparing has not been quantified with validated questionnaires. We report our experience with nerve-sparing orthotopic radical cystectomy and the impact on postoperative sexual function.

Combination therapy: medicated urethral system for erection enhances sexual satisfaction in sildenafil citrate failure following nerve-sparing radical prostatectomy.

The objective of our study was to assess the effectiveness of combining medicated urethral system for erection (MUSE) with sildenafil citrate in men unsatisfied with the sildenafil alone. Baseline and follow-up data from 23 patients (mean age, 62.5 +/- 5.23 years) unsatisfied with the use of the sildenafil citrate alone for the treatment of erectile dysfunction following nerve-sparing radical prostatectomy (mean use, 4 attempts/100-mg dose) was obtained. All patients started oral sildenafil citrate more than 6 months after radical prostatectomy. Combination therapy was initiated using 100 mg sildenafil citrate orally 1 hour prior to intercourse. Patients used combination therapy for a minimum of 4 attempts prior to assessment with the Sexual Health Inventory of Men (International Index for Erectile Function-5) and visual analog scale to gauge rigidity (0-100). The effect of therapy on the total International Index for Erectile Function (IIEF) score and penile rigidity score was assessed. Of the 23 patients, 4 (17%) had no improvement with the addition of medicated urethral system for erection and discontinued the drug, while 19 (83%) reported improvement with the penile rigidity and sexual satisfaction. The IIEF scores of these 19 patients showed significant improvements in each sexual domain, and the patients reported that erection was sufficient for vaginal penetration 80% of the time. Rigidity scores on a scale of 0-100 with sildenafil alone averaged 38% (23-53) for men and 46% (26-67) for their partners. With the addition of MUSE, scores increased to 76% for men and 62% for their partners. We conclude that the addition of MUSE to sildenafil improved sexual satisfaction and penile rigidity in patients unsatisfied with sildenafil alone.

Sling may hasten return of continence after radical prostatectomy.

OBJECTIVES: To place absorbable slings in 15 men at radical retropubic prostatectomy in an attempt to hasten recovery of continence. METHODS: Fifteen men underwent placement of a sling immediately after prostatectomy by a single surgeon. A strip of either porcine small intestine submucosa (SIS) or polyglactin mesh was placed beneath the anastomosis. The initial five slings were tension free. The last 10 were tightened just to the point they began to elevate the anastomosis. A comparison was made with the same number of men who underwent radical retropubic prostatectomy immediately before beginning this project. The average follow-up was 28.9 months. RESULTS: The first 5 sling patients (no tension) recovered complete bladder control in an average of 5.8 weeks. The 10 men with slings placed under slight tension were dry an average of 2.6 weeks after catheter removal, including 4 within 24 hours. One month later, 10 sling patients (67%) were continent, including 8 (80%) who had had the sling placed under slight tension. Six (40%) of 15 control patients were completely dry in that interval. Three months later, all but 1 sling patient (93%) was dry, but only 7 (47%) of 15 controls. All, except 1 control, were dry at 12 and 24 months. No complications were attributed to this maneuver, specifically no bladder neck contracture or retention occurred. No one in either group received incontinence treatment, although 2 control patients had either stricture or bladder neck contracture. CONCLUSIONS: The early results have been encouraging, but must be confirmed. Slight tension on the sling may be beneficial.