Health and Prostate

Preservation of sexual function has become an important consideration for our patients when contemplating therapeutic alternatives to their medical conditions and, in particular, surgical intervention. This concern has prompted the development of new surgical techniques and the modification of some old ones. In men we are interested specifically in preserving fertility, erectile function, and ejaculation. We can preserve these functions by timely corrective surgery, by modifying surgical techniques to avoid unwanted sequelae, or by substituting surgery for some other form of therapy less likely to produce unwanted complications. This article reviews the changes that have occurred in urology that allow us to offer our male patients better preservation of their sexual function. Table 1 lists urologic procedures that may be used to protect sexual function or that have the potential to interfere with sexual function. These procedures span the entire life of a male patient. Table 1. Genitourinary Surgical Procedures Affecting Potency And Fertility • Orchiopexy • Read more [...]

Prostate-Specific Antigen (PSA) is a serine protease normally produced by prostatic epithelial cells and present in high concentrations in prostatic secretions. In normal men, it is present in the serum in minute quantities. Most pathologic states involving the prostate, however, have the potential to cause marked elevations of serum PSA concentrations. Bacterial prostatitis, benign prostatic hyperplasia, and prostate cancer all elevate serum Prostate-Specific Antigen levels to varying degrees. Prostate-specific antigen has found the most widespread clinical application in the evaluation and management of patients with prostate cancer. Prostate-specific antigen has displaced prostatic acid phosphatase as the preeminent tumor marker for prostatic adenocarcinoma. The combination of several key features makes PSA unique among known tumor markers. It is remarkably sensitive to the presence of prostate cancer. Serum Prostate-Specific Antigen values are elevated in more than 95% of palpable cancers, including small palpable nodules (stage Bl lesions). Serum levels of Prostate-Specific Antigen are remarkably Read more [...]

Prostate specific antigen (PSA) has a reported sensitivity for prostatic adenocarcinoma of up to 80%. However, it lacks specificity. The reported positive predicted value of an elevated PSA (Hybritech Tandem-R PSA radioimmunoassay >4 ng/ml) for prostatic carcinoma in screening studies is only 28-33%. This is largely because 21-53% of men with benign prostatic enlargement (BPE) will have an elevated prostate specific antigen above 4 ng/ml. Prostatitis, including subclinical histologically proven inflammation, may lead to an elevated PSA. The physiological variation in serum PSA levels can be up to 30%. Nevertheless, serum prostate specific antigen is a useful tool in the detection and staging of organ-confined prostate cancer and the monitoring of disease progression and response to hormonal manipulation. We present a series of 31 men (mean age = 67 years; range = 48-82 years) who were referred to the urology unit over a 17-month period with a raised PSA, BPE on digital rectal examination, and a documented urinary tract infection (UTI). Five men were asymptomatic. The mean PSA (Hybritech Tandem-R Read more [...]

Discussion Simplified technology has made it feasible for most laboratories in Canada to assay prostate-specific antigen. Very little systematic information is available to suggest any uniformity across different geographic locations in the use of prostate-specific antigen. The volume of PSA testing has increased dramatically in most centres: the volume in our laboratory has doubled in 1 year, from about 250 per month in fall 1993 to 500 per month in fall 1994. Two randomized, controlled trials are under way to provide the essential information on outcome measures. The European Cancer Program is supporting a study in which asymptomatic adult men will have an initial prostate-specific antigen test and then will be placed (randomly) in a control group or in a screening group in which digital rectal examination and transrectal ultrasound (TRUS) will be performed. The NCI is funding a similar multicentre, randomized trial in which the screening group will be tested with DRE and PSA every 3 years and, if either has abnormal findings, patients will be subjected to TRUS. Initial results from these Read more [...]

Screening Cost per prostate-specific antigen test including labour is about $25. Even in a less populous province, such as Newfoundland, with about 50000 men between the ages of 50 and 75, annual screening would cost $1.25 million. This does not include additional costs arising from investigation of false-positive results. It is fair to state that mass screening for prostatic cancer with prostate-specific antigen is untenable. Evaluating PSA as a screening test for diagnosing prostatic cancer is difficult because the natural history of prostatic cancer is largely unknown. When prostate-specific antigen is used in casefinding, very high rates of sensitivity and specificity are observed; Powell et al found in a group of men presenting with urinary obstruction a sensitivity of 90% and a specificity of 90%, using 10 µg/L as the cutoff value for prostate-specific antigen. In studies where PSA has been used to detect prostatic cancer in asymptomatic populations (screening), these figures are less impressive, with a false-positive rate of 67 % in one study. Screening recommendations from professional Read more [...]

Casefinding Casefinding for prostatic cancer is the responsibility of family physicians, and the two tests available to them are digital rectal examination (DRE) and prostate-specific antigen. The arbitrary threshold value of 4.0 µg/L for prostate-specific antigen is most frequently used to distinguish normal from abnormal values. Depending on tumour location, DRE has a false-negative rate of 50% to 60%. Larger, rapidly growing cancers with poor prognosis are most likely to be found by digital rectal examination. Studies have shown that DRE does not significantly increase rates of detection over prostate-specific antigen testing. A limitation of prostate-specific antigen testing is that PSA levels are elevated during both benign and malignant diseases of the prostate. Three percent to 21 % of patients with BPH have PSA levels greater than 10 µg/L. Benign prostatic hypertrophy is far more common than prostatic cancer. Even among patients with PSA values of 11 to 23 µg/L, there are three benign prostatic hypertrophy patients to every two with prostatic cancer. On the other hand, 38% to 48% Read more [...]

The media bombard physicians and patients alike with information on prostate-specific antigen (PSA) testing. Consequently, men in their middle and later years are seeking medical advice about PSA testing. Increased numbers of tests are attended by increased numbers of false-positive results. I review the current status of prostate-specific antigen testing for early detection of prostate cancer. Background Prostate-specific antigen, produced exclusively in the prostate, is a glycoprotein with a molecular weight of 30000 to 34000 daltons. Its function in the seminal fluid is to break down the seminal clot. Increased prostate-specific antigen production is observed in patients with benign prostatic hypertrophy (BPH), prostatic cancer (PC), and prostatis. In other words, PSA production increases as prostatic epithelial cells proliferate, benign or malignant causes notwithstanding. Serum prostate-specific antigen concentration increases with age. A study of 103 patients at a prostate clinic showed that only 11 % of men younger than 60 had a PSA level greater than 4 µg/L, whereas 40% of men older Read more [...]

Surgery that threatens function Until now we have discussed surgery to prevent future impairment of sexual function. Much urologic surgery also has the potential to interfere with sexual function. New developments in surgical techniques are designed primarily to prevent such complications. Transurethral prostatectomy. More than 400 000 transurethral prostatectomies are performed in the United States. This is a safe and effective procedure but is associated with an almost 90% incidence of retrograde ejaculation and about 0.5% chance of impotence. Open prostatectomy for benign disease has a similar incidence of these complications. Impotence seems to occur more commonly in older patients and can have a psychosexual rather than an organic cause. In an effort to reduce many of the complications of prostatic surgery, several new techniques have been devised. Orandi has popularized a transurethral incision of the prostate, cutting the prostatic tissue from bladder neck to veru montanum without resecting any tissue. Although this procedure reduces the incidence of some complications, Read more [...]

Transurethral prostatic resection Efficacy. Lepor and Rigaud critically examined the efficacy of transurethral prostatectomy in men with moderate symptoms of prostatism. They assessed subjective outcome using a popular standardized symptom score formulated by Boyarsky and colleagues, as well as objective urinary flow rates. Urodynamic parameters alone cannot be used to assess efficacy, as it has been established that they do not correlate closely with symptoms. Approximately 85% of patients reported that symptoms were markedly improved after prostatic resection. The mean obstructive and irritative symptoms scores decreased 88% and 65%, respectively. Those who failed to improve had predominantly irritative symptoms. Mean peak urinary flow rate increased 108%. Abrams had previously reported a mean increase of more than 200%. Conversely, most studies on adrenergic blockade report mean peak urinary flow increases of 40% to 60%. The authors concluded that urinary flow rates and symptom scores improved more after transurethral prostatectomy than after any other therapeutic options Read more [...]

Prostate balloon dilation Large diameter (75F to 90F), high-pressure (3 to 5 atm) balloons have been developed to dilate the prostate and bladder neck in a manner similar to the use of Grunzig balloon catheters in vascular obstruction. Experience to date has been mixed. While some patients have had impressive objective and subjective improvement, most experienced a short-lived improvement or none at all. While the procedure is safe and well tolerated, the ideal patient has yet to be defined. Balloon dilation is an active area of clinical research. Improvements in equipment and more precise preoperative evaluation could result in a profile of the ideal patient who will achieve long-lasting benefit. Urethral stents Stents are cylinders of woven material, usually metal, which can be positioned across the bladder neck and prostate. They can be placed endoscopically or radiologically. They are stretched over an insertion device and placed in the urethra. When released, they resume their original shape, resulting in an opening force across the bladder neck and prostate. Stents Read more [...]