The post-finasteride syndrome: possible etiological mechanisms and symptoms

Finasteride and dutasteride, synthetic 5α-reductase inhibitors (5ARIs) are recommended in many guidelines for the treatment of benign prostatic hyperplasia/lower urinary tract symptoms and alopecia despite a variety of side effects like sexual, neurological, psychiatric, endocrinological, metabolic and ophthalmological dysfunctions and the increased incidence of high grade prostate cancer. The sexual side effects are common during the use of the drug but in a small subgroup of patients, they can persist after stopping the drug. This so-called post-finasteride syndrome has serious implications for the quality of life without a clear etiology or therapy. Three types of 5α-reductases are present in many organs in- and outside the brain where they can be blocked by the two 5ARIs. There is increasing evidence that 5ARIs not only inhibit the conversion of testosterone to 5α-dihydrotestosterone (DHT) in the prostate and the scalp but also in many other tissues. The lipophilic 5ARIs can pass the blood-brain barrier and might block many other neurosteroids in the brain with changes in the neurochemistry and impaired neurogenesis. Further research and therapeutic innovations are urgently needed that might cure or relieve these side effects. More awareness is needed for physicians to outweigh these health risks against the benefits of 5ARIs.

Maintaining bone health by estrogen therapy in patients with advanced prostate cancer: a narrative review

The purpose of androgen deprivation therapy (ADT) in prostate cancer (PCa), using luteinizing hormone-releasing hormone agonists (LHRHa) or gonadotrophin-releasing hormone antagonists, is to suppress the levels of testosterone. Since testosterone is the precursor of estradiol (E2), one of the major undesired effects of ADT is the concomitant loss of E2, causing among others an increased bone turnover and bone loss and an increased risk of osteoporosis and fractures. Therefore, the guidelines for ADT indicate to combine ADT routinely with bone-sparing agents such as bisphosphonates, denosumab or selective estrogen receptor modulators. However, these compounds may have side effects and some require inconvenient parenteral administration. Co-treatment with estrogens is an alternative approach to prevent bone loss and at the same time, to avoid other side effects caused by the loss of estrogens, which is the topic explored in the present narrative review. Estrogens investigated in PCa patients include parenteral or transdermal E2, diethylstilbestrol (DES), and ethinylestradiol (EE) as monotherapy, or high-dose estetrol (HDE4) combined with ADT. Cardiovascular adverse events have been reported with parenteral E2, DES and EE. Encouraging effects on bone parameters have been obtained with transdermal E2 (tE2) and HDE4, in the tE2 development program (PATCH study), and in the LHRHa/HDE4 co-treatment study (PCombi), respectively. Confirmation of the beneficial effects of estrogen therapy with tE2 or HDE4 on bone health in patients with advanced PCa is needed, with special emphasis on bone mass and fracture rate.

A Dose-Escalating Study With the Fetal Estrogen Estetrol in Healthy Men

CONTEXT

Luteinizing hormone-releasing hormone (LHRH) agonists have replaced estrogens for endocrine treatment of advanced prostate cancer (PC) because of cardiovascular side effects. The fetal estrogen estetrol (E4) may be safer for PC treatment and is expected to decrease testosterone (T) and prevent estrogen deficiency.

OBJECTIVE

To investigate the safety and T-suppressive effect of E4 in healthy men.

DESIGN

Double-blind, randomized, placebo-controlled, dose-escalating study.

SETTING

The study was conducted at a phase I clinical unit (QPS, Netherlands).

PARTICIPANTS

Healthy male volunteers aged 40 to 70 years.

INTERVENTION(S)

Three treatment cohorts of 15 volunteers with placebo (n = 5) and E4 (n = 10). Estetrol doses tested were 20, 40, and 60 mg/d. Subjects were treated for 4 weeks.

MAIN OUTCOME MEASURES

Subjective side effects, pharmacodynamic effects on hemostatic variables, lipids, glucose, bone parameters, and endocrine parameters related to T metabolism.

RESULTS

Total and free T decreased dose-dependently and significantly. Nipple tenderness occurred in 40% and decrease of libido occurred in 30% of E4-treated men. The unwanted estrogenic effects on hemostasis were small, dose dependent, and in some cases significant. Lipid and bone parameters showed a favorable trend.

CONCLUSION

The effect of E4 on testosterone levels is insufficient for standalone PC treatment. Taking all clinical and pharmacodynamic variables into consideration, a daily dose of 40 mg E4 seems safe for further evaluation of endocrine PC treatment in combination with LHRH analogs.

Precision surgery and genitourinary cancers

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.

Testosterone treatment is not associated with increased risk of prostate cancer or worsening of lower urinary tract symptoms: prostate health outcomes in the Registry of Hypogonadism in Men

OBJECTIVES

To evaluate the effects of testosterone-replacement therapy (TRT) on prostate health indicators in hypogonadal men, including rates of prostate cancer diagnoses, changes in prostate-specific antigen (PSA) levels and lower urinary tract symptoms (LUTS) over time.

PATIENTS AND METHODS

The Registry of Hypogonadism in Men (RHYME) is a multi-national patient registry of treated and untreated, newly-diagnosed hypogonadal men (n = 999). Follow-up assessments were performed at 3-6, 12, 24, and 36 months. Baseline and follow-up data collection included medical history, physical examination, blood sampling, and patient questionnaires. Prostate biopsies underwent blinded independent adjudication for the presence and severity of prostate cancer; PSA and testosterone levels were measured via local and central laboratory assays; and LUTS severity was assessed via the International Prostate Symptom Score (IPSS). Incidence rates per 100 000 person-years were calculated. Longitudinal mixed models were used to assess effects of testosterone on PSA levels and IPSS.

RESULTS

Of the 999 men with clinically diagnosed hypogonadism (HG), 750 (75%) initiated TRT, contributing 23 900 person-months of exposure. The mean testosterone levels increased from 8.3 to 15.4 nmol/L in treated men, compared to only a slight increase from 9.4 to 11.3 nmol/L in untreated men. In all, 55 biopsies were performed for suspected prostate cancer, and 12 non-cancer related biopsies were performed for other reasons. Overall, the proportion of positive biopsies was nearly identical in men on TRT (37.5%) compared to those not on TRT (37.0%) over the course of the study. There were no differences in PSA levels, total IPSS, or the IPSS obstructive sub-scale score by TRT status. Lower IPSS irritative sub-scale scores were reported in treated compared to untreated men.

CONCLUSIONS

Results support prostate safety of TRT in newly diagnosed men with HG.

Implant-Driven Tibial Nerve Stimulation in the Treatment of Refractory Overactive Bladder Syndrome: 12-Month Follow-up

Objectives.  To investigate feasibility and safety of implant-driven tibial nerve stimulation. Materials and Methods.  Eight patients with refractory overactive bladder were successfully treated with implanted percutaneous tibial nerve stimulation (PTNS). Patients were evaluated with bladder diaries, quality of life questionnaires, and physical examination before implantation, and at 3, 6, and 12 months of follow-up. The primary objective was ≥ 50% reduction of the number of incontinence episodes and/or voids on bladder diary. The Wilcoxon signed ranks test was used. Results.  At 3, 6 and 12 months, respectively five, six, and four patients met the primary objective. At 3- and 6-month follow-up, voiding and quality of life parameters had significantly (p < 0.05) improved. Urinary tract infection, temporarily walking difficulties, and spontaneous radiating sensations were reported as adverse events and no local infection, erosion, or dislocation. Conclusions.  Implant-driven tibial nerve stimulation seems to be feasible and safe.

Time to onset of action of vardenafil: a retrospective analysis of the pivotal trials for the orodispersible and film-coated tablet formulations

INTRODUCTION

Patients and physicians consider a rapid onset of action to be an important attribute of oral pharmacotherapy for erectile dysfunction.

AIM

To investigate the time to onset of action of a new orodispersible tablet (ODT) formulation of vardenafil.

METHODS

A post hoc integrated analysis was performed on data from two 12-week, double-blind, multicenter, randomized, parallel-group, placebo-controlled phase III trials of 10 mg vardenafil ODT. Data for the vardenafil film-coated tablet were generated from a retrospective integrated analysis at week 12 of four double-blind, multicenter, randomized, parallel-group, fixed-dose, placebo-controlled phase III trials. Time intervals (in 15-, 30-, and 60-minute increments, up to ≥6 hours after study medication intake) were determined for the period between dosing and start of sexual activity (with the intention of intercourse).

MAIN OUTCOME MEASURES

The total number of sexual intercourse attempts and Sexual Encounter Profile question 3 (SEP3) success rates were calculated per time interval.

RESULTS

Within 15 minutes postdosing, mean per-patient SEP3 success rates were 62.5% (vardenafil ODT) vs. 29.4% (placebo), with corresponding overall SEP3 success rates of 59.8% and 38.2%. In this time interval, 5.3% vs. 2.8% of all sexual activity attempts were initiated by subjects taking vardenafil ODT (n = 89) or placebo (n = 62), respectively. At 16-30 minutes postdosing, SEP3 success rates were 65.3% and 32.6% (mean per-patient) and 70.2% and 51.0% (overall) for vardenafil ODT vs. placebo, respectively, with a corresponding 10.4% and 8.7% of all sexual activity attempts being made by subjects taking vardenafil ODT (n = 170) or placebo (n = 118). Comparable results were observed for vardenafil 10 and 20 mg film-coated tablet at corresponding time intervals.

CONCLUSIONS

Vardenafil ODT shows a rapid onset of action comparable with that of vardenafil film-coated tablet. In those men who begin sexual activity within 30 minutes after dosing, the majority of sexual attempts lead to successful intercourse.

PSA velocity in conservatively managed BPH: can it predict the need for BPH-related invasive therapy?

OBJECTIVE

To study the value of PSA velocity (PSAV) to predict benign prostatic hyperplasia (BPH) progression in patients managed with alpha(1)-blockers or watchful waiting (WW).

METHODS

Nine hundred and forty two BPH patients treated with alpha(1)-blocker or WW were reviewed. PSAV was defined as: (PSA(t)-PSA(b))/(t/12); where PSA(t) = PSA at time of follow-up (t, in months), PSA(b) = PSA at baseline. PSA(t) was taken from the 1 year follow-up visit or, if not present, from the next available visit with a maximum of 24 months.

RESULTS

Five hundred and ninety five patients (234 alpha(1)-blocker, 361 WW) were included in the analyses. PSAV range was -5.24 to 43.06 ng/ml/year in alpha(1)-blocker patients and -6.11 to 19.55 ng/ml/year in WW patients (median: 0.01 ng/ml/year). PSAV was stratified into tertiles (Stable/Decrease/Increase). There were no significant differences in retreatment-free survival and the risk of BPH-related invasive therapy between the tertiles in both treatment groups.

CONCLUSIONS

PSAV did not predict BPH progression in either alpha(1)-blocker treated patients or WW group.

Percutaneous tibial nerve stimulation in the treatment of refractory overactive bladder syndrome: is maintenance treatment necessary?

OBJECTIVE

To determine the effect of a pause in percutaneous tibial nerve stimulation (PTNS) in successfully treated patients with an overactive bladder (OAB), and the reproducibility of successful treatment when restored.

PATIENTS AND METHODS

Eleven patients (mean age 51 years) with refractory OAB (more than seven voids and/or three or more urge incontinence episodes per day) were successfully treated with PTNS, and then discontinued treatment. Patients completed bladder diaries and quality-of-life (QoL) questionnaires (Short Form-36 and I-QoL) before (T1) and after a 6-week pause (T2) of maintenance PTNS, and again after re-treatment (T3). The first objective was defined as a > or = 50% increase in the incontinence episodes and/or voiding frequency in the bladder diary after T2. The second objective was defined as > or = 50% fewer incontinence episodes and/or voiding frequency in bladder diary after T3.

RESULTS

At T2, seven of the 11 patients had a > or = 50% increase in incontinence episodes and/or voiding frequency in the bladder diary. The mean voided volume, nocturia, number of incontinence episodes and incontinence severity deteriorated significantly (P < 0.05). At T3, nine patients had > or = 50% fewer incontinence episodes and/or voiding frequency in the bladder diary. Nocturia, the number of incontinence episodes, incontinence severity, mean voided volume and quality of life improved significantly (P < 0.05).

CONCLUSIONS

Continuous therapy is necessary in patients with OAB treated successfully by PTNS. The efficacy of PTNS can be reproduced in patients formerly treated successfully.

Design of clinical trials in advanced prostate cancer: avoiding the dead ends

Despite more than 30 years of clinical trials, investigations in prostate cancer have not succeeded in making advances comparable to those in other branches of research, such as breast cancer. Indeed, prostate cancer trials have repeatedly run into a series of "dead ends", as investigators face the problems of inadequate funding for research, treatments that result in only minimal improvements in survival, and lack of treatment options that have sufficient prospects for success. This article briefly reviews the strategies behind clinical investigations into prostate cancer over the last three decades, evaluates the pitfalls that have hindered research, and makes suggestions for the appropriate design of clinical trials that are safe and beneficial to patients while maintaining cost-effectiveness and accountability to patients and society.

Correlation between quality of life and voiding variables in patients treated with percutaneous tibial nerve stimulation

OBJECTIVE

To investigate the relationship between quality of life (QoL) and voiding variables in patients with lower urinary tract dysfunction treated with percutaneous tibial nerve stimulation (PTNS), as it is assumed that improvements in voiding will lead to a better QoL in such patients.

PATIENTS AND METHODS

The study included 30 patients with urge urinary incontinence who were treated with PTNS; 24-h bladder diaries and QoL questionnaires (Short Form, SF-36, and incontinence-specific QoL) were completed at baseline and after PTNS.

RESULTS

There was a significant correlation (P < 0.05) between the number of pads used and the SF-36 domains of physical and vitality, between the number of incontinence episodes and the SF-36 domains of physical and role physical, between nocturia and the SF-36 domains of general and mental health, between the mean voided volume and the SF-36 domains of role physical and final, and between the mean voided volume and the incontinence-specific QoL score.

CONCLUSIONS

PTNS is useful for treating refractory urge incontinence and should at least be considered as a therapeutic alternative before resorting to aggressive surgery, as voiding and QoL variables significantly and quantifiably correlate in patients with refractory urge urinary incontinence who are treated with PTNS. Patients must have a reduction of >or = two pads/day before their QoL improves, and this might be the best definition of successful therapy for patients with urge urinary incontinence.

Post-Void Residual Urine Volume is Not a Good Predictor of the Need for Invasive Therapy Among Patients With Benign Prostatic Hyperplasia

PURPOSE

We assessed the value of baseline PVR as predictor of the need for invasive therapy during long-term followup of patients with clinical BPH treated initially with alpha1-blockers or WW.

MATERIALS AND METHODS

The records of a cohort of 942 patients with BPH treated with alpha(1)-blockers or WW were reviewed. Baseline I-PSS scores, PSA, prostate volume, uroflowmetry, pressure flow parameters and followup data were collected prospectively. Correlations between PVR and other baseline parameters were calculated. The 5-year cumulative risks of invasive therapy were calculated with the Kaplan-Meier method. After stratification of PVR by various cutoff levels (50, 100 and 300 ml), rate ratios between large and small PVRs were calculated using proportional hazards analyses.

RESULTS

PVR has weak (-0.2<R <0.2) correlations with other baseline parameters. With increasing PVR cutoff levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45% to 64% and from 15% to 21% in the alpha1-blockers and WW group, respectively. Large PVR yields a significant 2-fold up to a 4-fold increased risk of invasive therapy compared to small PVR in both treatment groups. In multivariate models these significant risk differences largely disappear, although a statistically not significant higher risk remains for the large PVR (greater than 300 ml) patients.

CONCLUSIONS

In general, baseline PVR has little prognostic value for the risk of BPH related invasive therapy in patients on alpha1-blocker and WW. Only patients with large PVR have a 2-fold increased risk of invasive therapy compared to patients with smaller PVR.

Holmium:YAG laser for treatment of strictures of vesicourethral anastomosis after radical prostatectomy

BACKGROUND AND PURPOSE

Strictures of the vesicourethral anastomosis (VUA) following radical prostatectomy tend to recur. We used the holmium:YAG laser for treatment of recurrent stricture of the VUA. We evaluated the technique and its efficacy.

PATIENTS AND METHODS

In 10 patients, the Ho:YAG laser was used with a 365-mum fiber at a setting of 2 J and frequency 10 to 20 Hz, creating a deep incision of the scar tissue at the 6 o'clock position. This was followed by a vaporizing resection of the remaining scar tissue between 3 and 9 o'clock. We aimed to vaporize up to well-vascularized surrounding tissue. Retrospectively, the charts were reviewed for hospital stay, voiding complaints, recurrence of stenosis, complications, and flow rates. The mean follow-up was 18 months.

RESULTS

There were no operative complications. After removal of the catheter, all patients could void without difficulty. No re-treatment was needed for recurrent stenosis. Any existing irritative voiding complaints or incontinence did not change after treatment. In all patients, the flow pattern improved: the mean maximum flow rate increased, and the mean postvoiding residual volume decreased.

CONCLUSION

The Ho:YAG laser seems to be a safe and effective treatment for first or recurrent strictures of the VUA after radical prostatectomy.

Prognostic role of prostate-specific antigen and prostate volume for the risk of invasive therapy in patients with benign prostatic hyperplasia initially managed with alpha1-blockers and watchful waiting

OBJECTIVES

To investigate the prognostic role of prostate-specific antigen (PSA) level and prostate volume (PV) for the need for benign prostatic hyperplasia (BPH)-related invasive therapy among patients initially treated with an alpha1-blocker or watchful waiting (WW) in real-life clinical practice.

METHODS

Data were collected from 2264 consecutive patients with clinical BPH. Patients initially treated with an alpha1-blocker or WW were included in this study. They were stratified by baseline PSA level (less than 1.5, 1.5 to less than 3.0, 3.0 to 10.0 ng/mL) and PV (less than 30 and 30 to 200 cm3), and analyzed for the time to BPH-related invasive therapy.

RESULTS

Of the 2264 patients, 389 treated with alpha1-blockers and 553 who chose WW were included. Across the PSA and PV strata, the alpha1-blocker group had worse symptoms, peak flow, postvoid residual urine volumes, and obstruction than did the WW group. Increasing PSA levels produced an increase in the 5-year cumulative risk of invasive treatment: 20%, 34%, and 44% in the alpha1-blocker and 8%, 9%, and 15% in the WW group for a PSA level of less than 1.5, 1.5 to less than 3.0, and 3.0 to 10.0 ng/mL, respectively. The hazard ratio for the highest compared with the lowest PSA strata was 2.8 for alpha1-blocker and 2.7 for WW patients. An increasing PV increased the 5-year cumulative risk from 21% to 35% in the alpha1-blocker group and 8% to 11% in the WW group. The hazard ratio for the large versus small prostates in the alpha1-blocker group was 1.8 and in the WW group was 1.0.

CONCLUSIONS

A higher PSA level and larger PV resulted in a greater risk of BPH-related invasive therapy that was more pronounced in the alpha1-blocker than in the WW patients. However, symptom severity, flow parameters, and obstruction grade may have contributed to the difference in risk between the two treatment groups.

Recurrent pancreatitis after trimethoprim-sulfamethoxazole rechallenge

We report a female patient who repeatedly developed pancreatitis after trimethoprim-sulfamethoxazole (TMP/SMX) use. During childhood she had undergone an ureterosigmoidostomy after which she had been on TMP/SMX 480 mg daily as prophylaxis for pyelonephritis for many years. The patient presented with abdominal pain caused by acute pancreatitis. No other cause, except for TMP/SMX use, could be identified. A causal relationship was confirmed by relapse of the pancreatitis after rechallenge. Our case is unique in demonstrating that acute pancreatitis related to the use of TMP/SMX may occur even after long-term treatment. We advise that the medication is discontinued immediately if a causal relationship with pancreatitis is suspected.

Endocrine approaches in the therapy of prostate carcinoma

At present, the management of non-organ confined prostate cancer, whether it is a recurrence or metastasis, continues to evolve based on prostate cancer detection using prostate-specific antigen and the development of medications as alternatives for the classical orchiectomy, which induced irreversible implications for quality of life. Diethylstilbestrol therapy was associated with cardiovascular side-effects; GnRH agonists were able to create a castration level, but again considerable side-effects were described. Combination therapies using antiandrogens and GnRH agonists do not improve survival and have additional toxicity. GnRH antagonists, which also suppress FSH, represent the latest class of agents introduced for hormonal treatment, but phase III studies with survival data are not yet available. In spite of all these achievements, hormonal manipulation has resulted in only modest improvements during recent decades and new targets are needed to improve the clinical outcome. Selectively modifying the androgen receptor is currently one of the most promising developments.

Posterior tibial nerve stimulation in the treatment of voiding dysfunction: Urodynamic data

OBJECTIVES

To determine urodynamic changes and predictive factors in patients with voiding dysfunction who underwent 12 percutaneous tibial nerve stimulations.

METHODS

Thirty nine patients with chronic voiding dysfunction were enrolled in a prospective multicenter trial in the Netherlands (n = 19) and in Italy (n = 20). A 50% reduction in total catheterised volume per 24 hr was taken as a primary objective outcome measure. Patients' request for continuation of treatment was regarded as subjective success. Objective urodynamic parameters and bladder indices were determined. Odds ratios and their 95% confidence interval were computed as a measure for predictive power in order to reveal predictive factors (Pdet at Qmax, Qmax, BVE, and BCI).

RESULTS

Primary outcome measure was obtained in 41%, an additional 26% reduced their 24 hr residuals with more than 25%. Fifty nine percent of patients chose to continue treatment. Detrusor pressure at maximal flow, cystometric residuals, and bladder indices improved significantly for all patients (P < 0.05). Patients with minor voiding dysfunction were more prone to notice success (Odds ratio: 0.73; 95% CI: 0.51-0.94).

CONCLUSIONS

PTNS is a young treatment modality, minimally invasive, and easily accessible. It might be an attractive first line option for patients with (minor) voiding dysfunction.

Gonadotropin-releasing hormone antagonist in the management of prostate cancer

Luteinizing hormone-releasing hormone (LHRH) agonist therapy to induce medical castration has become the most common form of hormonal therapy for advanced and metastatic prostate cancer. When treatment is started, LHRH agonists initially stimulate the release of LH, causing a surge in serum testosterone that can precipitate a "flare" phenomenon or worsening of disease, particularly in patients with bone metastatic disease. Gonadotropin-releasing hormone (GnRH) receptor antagonism represents a newer approach to medical castration. Abarelix is a pure GnRH receptor antagonist that is devoid of any LHRH agonist activity. Results from 1 phase II and 3 phase III clinical trials demonstrate that abarelix produces medical castration more quickly and without causing testosterone surge, as compared with LHRH agonists with or without a nonsteroidal antagonist. The safety profile in terms of adverse events is comparable between the 2 types of treatment, but the lack of testosterone surge with abarelix might confer a safety advantage by abolishing the risk of a disease flare.

Prostate-Specific Antigen as an Estimator of Prostate Volume in the Management of Patients with Symptomatic Benign Prostatic Hyperplasia

OBJECTIVES

To assess the ability of serum prostate specific antigen (PSA) to estimate prostate volume (PV) to aid in the management of patients with benign prostatic hyperplasia (BPH).

METHODS

From 1989 to 2002, data were collected from 2264 patients complaining of lower urinary tract symptoms (LUTS) who visited the Department of Urology of the University Medical Centre Nijmegen, The Netherlands. Baseline PV and serum PSA was determined using standard techniques. All patients who had a baseline PV < or =200 ml, as well as a baseline serum PSA 0-10 ng/ml, were included. Patients with a history of prostate surgery, prostate cancer and conditions other than BPH at baseline were excluded. A log-transformed linear regression model was used to estimate PV. Receiver-operating characteristic (ROC) curves were constructed to evaluate the ability of serum PSA to estimate threshold PVs in men with BPH, and to select the optimal serum PSA cut-off values.

RESULTS

The analyses included 1859 patients with a mean age of 63.5 years, mean baseline PV 43.9 ml, and mean baseline PSA value 3.1 ng/ml. PV as well as serum PSA increases with age. Linear regression analyses showed that PV and serum PSA have an age-dependent log-linear relationship, where 42% of the variance of PV can be explained by PSA and age. ROC's area under the curves (AUC) reveal that PSA has a good predictive value for assessing 'prostate enlargement', with AUC around 82% in the overall age groups irrespective of the PV cut-off values. Optimal serum PSA cut-off values for the overall study population irrespective of age are 2.0 ng/ml to detect PV >30 ml and 2.5 ng/ml to detect PV >40 ml.

CONCLUSIONS

This study suggests that serum PSA can estimate prostate enlargement sufficiently accurately to be useful for therapeutic, especially medical, management. It is well accepted that the outcome of pharmacotherapy for BPH depends on baseline PV. Therefore, in the absence of reliable direct measurement of PV, serum PSA determination may be used to optimise patient management.

Transurethral resection vs microwave thermotherapy of the prostate: a cost-consequences analysis

OBJECTIVE

To compare the costs and outcome of high-energy transurethral microwave thermotherapy of the prostate (HE-TUMT) with transurethral resection of the prostate (TURP), as the former is considered to be the best minimally invasive method for managing lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Between January 1996 and March 1997, 144 patients were randomized to treatment with HE-TUMT (78) using the Prostatron device and Prostasoft 2.5 software (EDAP Technomed, Lyon, France), or TURP (66). At baseline and during the annual follow-up, patients were evaluated by the International Prostate Symptom Score and uroflowmetry (maximum flow rate and postvoid residual volume). Kaplan-Meier survival analyses were used to calculate the cumulative risk of re-treatment. A cost-consequences analysis was performed based on the prospective measurement of healthcare use, with costs expressed as Netherland guilders (NLG).

RESULTS

During a 3-year follow-up period, the mean (95% confidence interval) risk of re-treatment was 22.9 (12.5-33.2)% and 13.2 (4.5-21.9)% for HE-TUMT and TURP, respectively (P = 0.215). The mean direct cost of treatment was 3450 (3444-3456) and 6560 (5992-7128) NLG for HE-TUMT and TURP, respectively. The mean total (including re-treatments), discounted (4%) 3-year cost for the HE-TUMT and TURP group was 5300 (4692-5908) and 7800 (7118-8482) NLG, respectively.

CONCLUSIONS

In this prospective randomized trial, HE-TUMT and TURP had a comparable 3-year risk of re-treatment. Healthcare expenditure on HE-TUMT, mainly because it is an outpatient treatment, was significantly lower than for TURP.

A randomized study comparing epirubicin in a 4-weekly versus a weekly intravenous regimen in patients with metastatic, hormone resistant, prostatic carcinoma: effects on health related quality of life

The treatment of hormone resistant prostate cancer) with epirubicin 25 mg/m(2)(Epi25) on a weekly intravenous regimen may be better in terms of health related quality of life (HRQOL) than with 100 mg/m(2)(Epi100) on a 4-weekly regimen. A total of 79 patients who filled out the EORTC-QLQ-C30 questionnaire for the assessment of HRQOL could be evaluated. Compared with the baseline, no changes in HRQOL function scales or significant changes in the following HRQOL symptom scales were found. The Epi25 group reported less pain during the first 3 months and the Epi100 group more dyspnoea after 4 weeks and less pain and less insomnia but more loss of appetite after 8 weeks. In both groups, toxicity was comparable, except for World Health Organisation grade II-III alopecia occurring in 82% in the Epi100 versus 31% in the Epi25 group. There were no significant differences between groups in response rates and survival. In this study, HRQOL was not improved which is in line with other studies using only epirubicine. Epirubicin as single agent therapy should not be used in future treatment of patients with HRPC.

Percutaneous tibial nerve stimulation in the treatment of overactive bladder: urodynamic data

AIM

The aim of this study was to evaluate urodynamic changes after percutaneous tibial nerve stimulation (PTNS) for the treatment of complaints related to overactive bladder syndrome and to search for urodynamic-based predictive factors.

METHODS

Ninety consecutive patients with symptoms related to overactive bladder syndrome were enrolled in this study. Patients underwent 12 PTNS sessions. For evaluating objective success, the primary outcome measure was a reduction in number of urinary leakage episodes of 50% or more per 24 hours. Patients' request for continuation of therapy was considered subjective success. This study focussed on urodynamic features at baseline and on changes found after 12 PTNS treatments.

RESULTS

The objective success rate was 56% (leakages/24 hours). Subjective success rate was 64%. Frequency/volume chart data and quality of life scores improved significantly (P < 0.01). Pre- and posturodynamic data were available from 46 participants. Detrusor instabilities (DI) could be abolished in a few cases only. Increments in cystometric bladder capacity and in volume at DI were significant (P = 0.043 and 0.012, respectively). Subjects without detrusor instabilities at baseline were 1.7 times more prone to respond to PTNS (odds ratio, 1.75; 95% confidence interval [CI], 0.67-4.6). The more the bladder overactivity was pronounced, the less these patients were found to respond to PTNS, the area under the receiver operating curve was 0.644 (95% CI, 0.48-0.804).

CONCLUSION

PTNS could not abolish DI. PTNS increased cystometric capacity and delayed the onset of DI. Cystometry seemed useful to select good candidates: patients without DI or with late DI onset proved to be the best candidates for PTNS.

Posterior tibial nerve stimulation in the treatment of urge incontinence

AIMS

The objective of this study was to evaluate the effect of posterior tibial nerve stimulation (PTNS) for treatment of urge incontinence.

METHODS

In a prospective multicentre study, 35 patients with complaints of urge incontinence underwent 12 weekly sessions of PTNS at one of five sites in the Netherlands and one site in Italy. Frequency/volume charts and I-QoL and SF-36 questionnaires were completed at 0 and 12 weeks. Success was analysed by using subjective and objective criteria. Overall subjective success was defined as the willingness to continue treatment, whereas objective success was defined as a significant decrease (to<50%) in total number of leakage episodes.

RESULTS

Twenty-two patients (63%) reported a subjective success. Twenty-four patients (70%) showed a 50% or greater reduction in total number of leakage episodes. Sixteen (46%) of these-patients were completely cured (i.e., no leakage episodes) after 12 sessions. Quality of life parameters improved significantly.

CONCLUSIONS

We conclude that posterior tibial nerve stimulation is an effective, minimally invasive option for treatment of patients with complaints of urge incontinence, as improvement was seen in subjective as well as objective parameters.

Posterior tibial nerve stimulation in the treatment of idiopathic nonobstructive voiding dysfunction

OBJECTIVES

To evaluate the effect of stimulation of the posterior tibial nerve in the treatment of voiding dysfunction.

METHODS

Thirty-nine patients with chronic voiding dysfunction necessitating clean intermittent catheterization were enrolled in a prospective multicenter trial in the Netherlands (n = 19) and Italy (n = 20). They underwent 12 weekly sessions of posterior tibial nerve stimulation. Frequency/volume charts, an incontinence quality-of-life instrument, and the MOS 36-item Short-Form Health Survey were completed at 0 and 12 weeks. Subjective success was defined by the patient's positive response resulting in a request to continue treatment. Efficacy was based on analysis of the frequency/volume charts comparing the baseline values with the data at 12 weeks. A reduction of 50% or more in total catheterized volume was considered as an objective success (primary outcome measurement).

RESULTS

Of the 39 patients, 23 (59%) chose to continue treatment. The frequency/volume charts showed a 50% decrease in total catheterized volume in 16 (41%) of 39 patients. Additionally, 10 patients (26%) noted a reduction of 25% to 50% in their total catheterized volume. For all patients, the total catheterized volume decreased by a mean of -228 mL (range -49 to -528). The incontinence quality-of-life instrument and Short-Form Health Survey parameters improved significantly.

CONCLUSIONS

Percutaneous stimulation of the posterior tibial nerve seems to be an effective, minimally invasive option worth trying in patients with idiopathic voiding dysfunction. Improvement was seen in objective micturition parameters, as well as in subjective quality-of-life data.

Percutaneous tibial nerve stimulation as neuromodulative treatment of chronic pelvic pain

PURPOSE

Neuromodulative therapies have been used with moderate success in patients with chronic pelvic pain. Intermittent Percutaneous Tibial Nerve Stimulation (PTNS) is a new, minimally invasive treatment option, which has shown to significantly decrease accompanying pain complaints in patients with lower urinary tract dysfunction, such as urge incontinence or urgency/frequency. In our study, we evaluate the objective results of PTNS in patients with chronic pelvic pain as their main complaint.

MATERIALS AND METHODS

In a prospective multicentre trial PTNS was evaluated in 33 patients with chronic pelvic pain. Effects were recorded by Visual Analogue Scale (VAS) for pain diaries, the McGill pain questionnaire and the SF-36 general quality of life questionnaire at baseline and after 12 weeks of treatment. Subjective (patients' request to continue chronic treatment to keep the obtained success) and objective responses (decrease in mean VAS >50% and VAS <3 after treatment) were evaluated.

RESULTS

A subjective response was seen in 42% of all patients. In seven patients (21%) mean VAS decreased >50%, in six cases (18%) the decrease was >25%. After 12 weeks of treatment, seven patients (21%) ended up with a mean VAS <3. In all patients quality of life (SF-36) significantly improved, as did the total pain rate intensity (McGill).

CONCLUSIONS

Despite very modest overall success rates and the need for placebo-controlled studies, PTNS may have a place in the treatment of patients with chronic pelvic pain who have already tried many other therapies and are left with no further option.

Correlation of transrectal ultrasound, computer analysis of transrectal ultrasound and histopathology of radical prostatectomy specimen

A system for computerised analysis of ultrasonographic prostate images (AUDEX=Automated Urologic Diagnostic EXpert system) for the detection of prostate carcinoma was developed. The ultimate goal is to develop a system that is reliable and non-observer dependent. Results of an earlier study with a small group were encouraging and this study describes the results of the computerised analysis in a larger group. Sixty-two patients who were scheduled to undergo a radical prostatectomy were prospectively analysed. The radical prostatectomy specimens were step-sectioned in the transverse plane, corresponding to the ultrasound pictures. Malignant regions identified by each study were quantified and compared by computer calculation. No correlation was observed between ultrasound analysis and pathology result. For the AUDEX analysis an overall sensitivity of 85% and a specificity of 18% with only a diagnostic accuracy of 57% was noticed when presence or absence of malignancy was evaluated by octant (total 496). When applying a cut-off value of 0.5 ml the numbers were 71%, 33% and 55%, respectively. Correlation was significantly better for the ventral octants. In this study the earlier results of our AUDEX system could not be confirmed. Although sensitivity was good, specificity and especially diagnostic accuracy were lower than expected. We have to conclude that the current settings are inappropriate for routine clinical use. Prostate Cancer and Prostatic Diseases (2001) 4, 56-62

Vaccination of patients with metastatic renal cell carcinoma with autologous dendritic cells pulsed with autologous tumor antigens in combination with interleukin-2: a phase 1 study

Dendritic cells (DC) have been recognized as the most potent antigen presenting cells (APC) of the immune system. We performed a phase 1 study in twelve patients with metastatic renal cell carcinoma (RCC) using autologous immature DC loaded with autologous tumorlysate (TuLy) as a vaccine based on our earlier in vitro observations that such DC can activate tumor-specific cytotoxic T-lymphocytes. The treatment was combined with low-dose interleukin (IL)-2, as this has shown benefit in DC-based therapies. Patients received three intradermal vaccinations at two weekly intervals, and, after each vaccination, IL-2 was administered for 5 consecutive days. In six patients, keyhole-limpet hemocyanin (KLH) was added to the DC culture for immunologic monitoring purposes. In general, DC phenotype was CD14(low), CD86(high), CD40(high), CD80(low), and CD83(low). We noticed that the number of CD14+ cultured DC increased during treatment. Nevertheless, ovalbumin uptake remained high, underlining that these cells were still functional immature DC. The vaccine was able to elicit cellular anti-KLH responses, emphasizing the ability of the injected DC to mount an immunologic response. However, proliferative responses against TuLy were not detected, and humoral responses against TuLy or KLH were absent. Objective clinical responses were not observed, but extended stable disease was noted. The absence of cellular, humoral, or clinical antitumor responses suggests that the vaccination strategy with immature DC has little benefit for patients with advanced RCC. Nevertheless, this study shows the feasibility of a completely autologous DC and tissue culture methodology for the generation of TuLy pulsed DC.

Important factors in the diagnosis and primary staging of testicular tumours

PURPOSE OF REVIEW

In the present review we outline the use of different staging methods and highlight future possibilities in the management of testicular germ cell cancer.

RECENT FINDINGS

The 5-year survival for testicular cancer has improved dramatically over the past 30 years, with cure rates approaching 95%. This success is attributed to the appropriate integration of effective treatments and staging modalities. Staging currently represents the cornerstone on which treatment is based. Because most patients will be cured, attention has shifted toward reducing morbidity of treatment while maintaining high cure rates. This implies that staging must be accurate before any change to the treatment regimen can be instituted.

SUMMARY

Effective management of testicular germ cell cancer continues to pose a major challenge. Early and accurate diagnosis is very important because it will influence the choice of treatment and thus may impact on prognosis.

Long-term results of ileum interposition for ureteral obstruction

OBJECTIVE

To present the long-term results of ileum interposition in the ureter for uni- or bilateral ureteral obstruction.

PATIENTS AND METHODS

Between 1981 and 2000, a total of 22 patients received an ileal segment interposition as a substitution for the ureter, of whom 18 were available for analysis. The mean age was 54 years (range 29-73). Patients were followed for a mean period of 65 months (range 2-196). Assessment included clinical examination, serum creatinine levels, renal ultrasonography, intravenous pyelography and isotopic renography. In eight patients, the ileal-ureteral substitution was the first reconstructive procedure. The other patients underwent up to four previous reconstructions of different types. Fourteen patients were treated for unilateral ureteral obstruction, four of whom had a functional or anatomical solitary kidney, the other four patients had bilateral obstruction.

RESULTS

In 16 patients renal function improved after ileal-ureteral substitution. One patient underwent a nephrectomy because of a decreased renal function due to an obstruction at the level of the uretero-ileal anastomosis. One patient had a nephrectomy because of recurrent macroscopic hematuria caused by multiple arterio-venous malformations. Overall, 15 patients (83%) had a good functioning kidney after a mean period of 65 months. In three patients an early reintervention was necessary because of bleeding, small bowel obstruction and urinary leakage from a pyelo-ileal anastomosis. Six patients required a reintervention in the long-term: two had a nephrectomy, three had a re-anastomosis between the renal pelvis and the proximal ileal segment, while the sixth patient underwent a PNL for a kidney stone. Recurrent urinary tract infections were seen in six patients, of whom three had to undergo a reintervention. Metabolic acidosis was detected in two patients and was treated with sodium bicarbonate substitution.

CONCLUSION

Ileal-ureteral substitution is a valuable procedure with good long-term results and an acceptable rate of secondary interventions in patients for whom other alternatives are not feasible.

A shared care approach to the management of erectile dysfunction in the community

Erectile dysfunction (ED) affects men of all ages and results in considerable distress and impact on quality of life for those who suffer from it. As ED is associated with a wide variety of under-lying conditions and cardiovascular co-morbidities, there is a requirement for diversity of treatment options and several factors must be considered to customise and optimise therapy. In the ideal holistic approach to management of the ED patient, both primary care and specialist physicians have an important role to play. This article reports on a sequential approach for the diagnosis and treatment of ED, with an emphasis on 'shared care'. The deliberations are based on a pan-European inter-disciplinary group that met at the Lygon Arms, UK on 22 February 2002.

Baseline prostatic specific antigen does not predict the outcome of high energy transurethral microwave thermotherapy

PURPOSE

We assessed the prognostic value of baseline prostate specific antigen (PSA) for outcome after high energy transurethral thermotherapy in patients with lower urinary tract symptoms.

MATERIAL AND METHODS

Data were collected prospectively in 404 consecutive patients treated with high energy transurethral thermotherapy with the Prostatron device (EDAP-Technomed, Lyon, France). Patients were followed a minimum of 1 year. At baseline certain criteria were assessed, including pretreatment PSA, uroflowmetry, ultrasound measurement of prostatic volume, voided and post-void residual urine volume, and International Prostate Symptom Score (I-PSS) and quality of life scores. Outcome assessment included I-PSS, quality of life score and uroflowmetry of peak urine flow. Linear regression analyses were performed to correlate baseline PSA with improved clinical parameters at 12 months of followup. Logistic regression analyses and receiver operating characteristics curves characterized the ability of baseline PSA to discriminate patients with a more or less favorable outcome.

RESULTS

An evident linear association was identified for prostate size at baseline and PSA. After 1 year 36 patients were treated again due to transurethral thermotherapy failure and 16 had died, which was not related to lower urinary tract symptoms or treatment for lower urinary tract symptoms. To include re-treated patients in the analyses we considered that their I-PSS, quality of life and peak urine flow values at 1 year were unchanged compared with baseline. Of the 388 evaluable patients an improvement of 50% or more in I-PSS, quality of life and peak urine flow was observed in 57%, 62% and 44%, respectively. Absolute mean changes at 1 year were -9.7, -2 and 5.2 ml. per second for I-PSS, quality of life and peak urine flow, respectively. Neither linear nor logistic regression analysis showed any clinically relevant correlation between baseline PSA and changes in I-PSS (r = -0.004), quality of life (r = -0.135) or peak urine flow (r = 0.105) at 1 year. Receiver operating characteristics curves failed to distinguish more or less favorable outcomes in all evaluated parameters.

CONCLUSIONS

Pretreatment PSA cannot predict the clinical outcome after high energy transurethral thermotherapy.

Recent developments in guidelines on benign prostatic hyperplasia

Guidelines within the healthcare system aim to rationalize the diagnosis, treatment and follow-up of a particular disease and can be applicable on an international scale or may be country specific. Specialists, who determine the clinical evidence for individual practices, prepare these guidelines, and the strength of these recommendations depends on available evidence. The assessment of patients includes a minimal number of non-invasive tests. Only in cases of abnormalities are additional (more invasive) tests recommended. Treatment decisions should be evidence-based but, despite guidelines, the choice of treatment is often highly dependent on the personal preference of the urologist. Patients' awareness of different treatment options and their involvement in choosing a treatment is also increasing. Economical aspects are becoming more and more important in making healthcare decisions. Data on durability of treatments, however, are limited and deserve special attention in order to provide the most cost-effective care for different patient groups.

Transrectal ultrasound imaging of the prostate: review and perspectives of recent developments

We present a critical review of the recent literature and discuss the development and prospective view of the evaluations of transrectal ultrasound with regard to prostate malignancy. We illustrate this with personal experiences. Material and Methods: Based on a critical evaluation of clinical data we address the apparent shortcoming of greyscale transrectal ultrasonography in the assessment of prostate cancer. New developments and future possibilities are also discussed. Evaluation of the value of greyscale transrectal ultrasonography in the diagnosis of prostate cancer indicates a limited role, because of the non-uniform appearance of prostate cancer on the ultrasound images. Ameliorating of transrectal ultrasound, like the use of contrast ultrasonography, could improve the detection of prostate cancer. Although the use of greyscale transrectal ultrasonography lacks sensitivity and specificity for the diagnosis of prostate cancer, its use in volume measurement of the prostate and biopsy guidance is unquestionable. The first results of the application of contrast ultrasonography are promising, both in detection of prostate cancer as in treatment follow up. Other developments like improvement of transducer and computer technology could make the use of ultrasound more versatile. However, future research will indicate whether all these improvements will lead to clinical applications.

High energy transurethral thermotherapy in the treatment of benign prostatic hyperplasia: criteria to predict treatment outcome

In this study we analyzed the individual value of baseline parameters to predict the outcome of high energy transurethral microwave thermotherapy in the treatment of patients with lower urinary tract symptoms and benign prostatic hyperplasia. Two hundred and forty-seven patients with symptomatic benign prostatic hyperplasia were treated with high energy microwave thermotherapy using the software 2.5 (Prostatron). Mean age at the time of treatment was 66.3 (s.d. 8.2) y, the mean prostate volume 57.0 (s.d. 25.2) cc and the mean energy applied was 159 (s.d. 40) KJ. Multi variable analysis on baseline parameters was performed to evaluate their predictive value for response using the WHO-response evaluation criteria for IPSS, maximum flow and urodynamic obstruction (linPURR). At 1 y follow-up a 57% increase in maximum flow and a 59% decrease in symptom score was noticed following high energy transurethral thermotherapy. The percentage of good responders varies between 12% and 34% depending on the stratification (IPSS, Q(max) and linPURR), the percentage of intermediate responders in these categories varies between 17% and 60% and the percentage of poor responders varies between 20% and 49%. Independently predictive baseline parameters for poor response were patients' age, prostate size and grade of bladder outlet obstruction (BOO). The total amount of energy delivered during treatment is also correlated with response. For the case selection for high energy transurethral microwave thermotherapy three baseline parameters can be identified which predict response for at least one response evaluation criterium: age, prostate size, grade of bladder outlet obstruction (BOO) and total amount of TUMT-energy. Especially the total amount of TUMT-energy is strongly predictive for all three response evaluation criteria, which suggests an important contribution of other mechanisms such as vascularisation and tissue composition to the outcome of high energy TUMT treatment.