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Prostate-Specific Antigen (PSA)

Posted by admin on November 29th, 2009 No Comments

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 proportional to both clinical stage and pathologic stage found at radical prostatectomy. In fact, careful pathologic studies show that serum PSA is directly proportional to the volume of prostate cancer. Because the clinical and pathologic stages of prostate cancer, perhaps more so than any other malignant neoplasm studied, also appear to be a direct function of tumor volume, Prostate-Specific Antigen has proved a useful adjunct in staging. In untreated patients with prostate cancer who have undergone careful pathologic staging, it is almost unheard of to find regional lymph node metastases when serum Prostate-Specific Antigen levels are less than 10 µg per liter by the Yang assay (about 5.5 µg per liter by the more commonly used Hybritech assay). In untreated patients with serum PSA levels above 75 µg per liter by the Yang assay (50 µg per liter by the Hybritech assay), nearly two thirds have lymph node metastases, three quarters have seminal vesical invasion by cancer, more than four fifths will have extensive tumor volume and surgical margin involvement, and all will have high-grade lesions. Unfortunately, as with any biologic system — especially a deranged biologic system, which cancer is by definition — exceptional patients with high-volume prostate cancers and high serum Prostate-Specific Antigen values may have organ-confined disease, and patients with low-volume tumors and low PSA values may have early metastases. Also, because

Prostate-Specific Antigen is nonspecific for prostate cancer, serum levels may be elevated by coexistent prostatic disease, including bacterial prostatitis and benign prostatic hyperplasia. Therefore, although a valuable adjunct to our current clinical staging of patients with prostate cancer, measuring the PSA level does not eliminate the need for careful clinical assessment, including a digital rectal examination, technetium bone scans, and appropriate radiographic studies.

Prostate-specific antigen provides an excellent objective measure in observing patients with prostate cancer. Serum Prostate-Specific Antigen levels rise over time and correlate with clinical progression of the disease process in untreated patients with prostate cancer. Moreover, exponential increases in serum PSA levels usually precede clinical disease progression and may allow preemptive treatment planning. Any successful treatment of prostate cancer dramatically affects serum Prostate-Specific Antigen levels. In patients responding to androgen ablation, serum PSA levels fall precipitously, with nadir values typically reached by 3 to 6 months. After radiotherapy, Prostate-Specific Antigen values fall in a similar manner but with a more prolonged time course, and nadir values are reached at 12 to 18 months. Patients for whom either androgen ablation or radiotherapy fails also behave similarly, with exponentially rising serum PSA values usually preceding symptomatic clinical recurrence or progression.

One clearly defined use for Prostate-Specific Antigen is in observing patients after radical prostatectomy. These patients, if their cancer and prostate are completely surgically excised, should have no PSA in their serum. Given the serum half-life of the Prostate-Specific Antigen molecule (between 2.2 and 3.2 days), most patients should have zero serum PSA values by three weeks, and all should be zero by six weeks. The persistence or recurrence of Prostate-Specific Antigen in the serum after radical prostatectomy accurately predicts residual or metastatic cancer and usually presages clinical disease recurrence by many months or years.

Posted in Prostate Gland

Prostate specific antigen in urinary tract infection

Posted by admin on November 28th, 2009 No Comments

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 PSA radioimmunoassay) at presentation was 24 ng/ml, with a range of 5.4-100 ng/ml (normal range = 0-4 ng/ml).

A clinically significant UTI (>105 organisms per ml) was documented in all 31 patients. Following eradication of the urinary tract infection, the prostate specific antigen returned to normal (mean = 2.7 ng/ml; range = 0.3-3.9 ng/ml) in 81% of cases (25) within 17 weeks. In the remaining six cases, the PSA fell after treatment but remained persistently elevated above the normal range (9.7 ng/ml; range = 4-14.9 ng/ml). Eleven of the symptomatic cases became asymptomatic after treatment.

The failure of the prostate specific antigen to return to normal in six cases may be due to bulky benign prostate hyperplasia or an age-related variation in PSA. However, this group requires careful urological follow-up.

An uncomplicated urinary tract infection in men with benign prostatic enlargement appears to be the cause of an elevated PSA. Following eradication of the UTI, the prostate specific antigen normalizes in the majority of cases. The half-life of PSA is between 2.2 and 3.15 days. Estimation of the serum prostate specific antigen in men with benign prostatic enlargement on digital rectal examination with a suspected or documented urinary tract infection is therefore not recommended for a period of at least six weeks after successful antibiotic treatment. This will reduce the number of patients undergoing negative prostatic biopsies — a procedure not without an associated morbidity.

Posted in Prostate Gland

Early detection of prostate cancer. Part 4

Posted by admin on November 28th, 2009 No Comments

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 trials will be available in about 7 years.

The natural progression of prostatic cancer is benign, though not universally so. Routine screening of asymptomatic men with prostate-specific antigen increases the detection rate of prostatic cancers that would not affect the longevity or even the quality of life of many men. However, faced with a diagnosis of cancer, most men opt for surgery or radiation therapy rather than take the chance that their cancer will not advance. In spite of improved surgical techniques, postoperative complication rates of impotence and urinary incontinence are high.

Wasson et al have reviewed the literature from 1982 to 1992 and give the following mean complication rates for total prostatectomy: incontinence 26.6%, impotence 85%, impotence following nerve-sparing surgery from two series 32%. Complication rates were slightly lower with radiation therapy. Most of these men (who had localized prostatic cancer) were symptom free, but must now live with complications for the rest of their lives. Chodak worked out the average mortality after radical prostatectomy (from reports published in academic centres) to be 1%, with a range of 0.5% to 3.0%.

Conclusion

Use of prostate-specific antigen for early detection of prostatic cancer is not supported by scientific evidence at present, and risk-to-benefit analysis is incomplete. If early detection of prostatic cancer is discussed during a periodic physical examination of a man between 50 and 70 years, some of these salient points should be brought up. If a decision is made to evaluate the prostate, do a PSA test and a digital rectal examination; if not, neither prostate-specific antigen nor DRE need be done.

Genitourinary symptoms and family history of prostatic cancer strongly indicate that a prostate-specific antigen test and a digital rectal examination should be done. If PSA levels are abnormally elevated, if patients have urinary symptoms requiring surgical evaluation, or if DRE findings are suspect, patients should be referred to urologists for further evaluation. ■

Posted in Prostate Gland

Early detection of prostate cancer. Part 3

Posted by admin on November 28th, 2009 No Comments

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 groups

Neither the Canadian Task Force on the Periodic Health Examination (CTFPHE) nor the United States Preventive Services Task Force (USPSTF) advises routine testing for prostatic cancer; both base their recommendation on a formal appraisal of prevailing scientific evidence. The Canadian Cancer Society has not recommended screening with prostate-specific antigen. The National Cancer Institute (NCI) in the United States advises physicians:

Given the possibility of unnecessary morbidity associated with diagnosis and treatment of many such lesions, careful evaluation of prostate cancer screening is desirable. There is insufficient evidence to recommend transrectal ultrasound and serum tumour markers for routine screening in asymptomatic men.

Contrary to most cancer organizations in North America, the American Cancer Society recommends annual screening for all men older than 50 by both digital rectal examination and prostate-specific antigen. Both the American Urological Association and the Canadian Urological Association recommend annual screening for men 50 to 70 years with both DRE and PSA. The Canadian Urological Association’s recommendations were not accompanied by a presentation of supporting scientific evidence or of the process by which they were developed.

Posted in Prostate Gland

Early detection of prostate cancer. Part 2

Posted by admin on November 28th, 2009 No Comments

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% of patients with organ-confined prostatic cancer, the ideal candidates for therapy with the best chances of being cured, have prostate-specific antigen levels in the normal range. These figures emphasize the overlap in concentration of prostate-specific antigen in patients with benign prostatic hypertrophy and prostatic cancer. Bernstein et al, using Shannon entrophy calculations to determine optimum decision levels, concluded that 11 to 23 µg/L PSA levels are probably an equivocal region in which the frequency of BPH is about 1.5 times that of prostatic cancer. For older men, the long natural history of PC and the risks of surgery make total prostatectomy undesirable, thus removing most of the reasons for casefinding.

Diagnosis

Definitive diagnosis and treatment of prostatic cancer are the responsibility of urologists, to whom patients are referred because of urinary symptoms requiring surgical evaluation, suspect findings on DRE, or elevated serum prostate-specific antigen. A serious drawback of PSA is its lack of specificity for prostatic cancer, resulting in the need for further investigation of false-positive results with transrectal ultrasound (TRUS) and biopsy. Transrectal ultrasound is expensive and has limitations. Prostatic biopsy (the criterion standard) remains the confirming test for prostatic cancer, but is invasive and subject to error; detection rates for prostatic cancer range from 0.3% to 14.5%.

Posted in Prostate Gland

Early detection of prostate cancer. Part 1

Posted by admin on November 28th, 2009 No Comments

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 than 60 had a prostate-specific antigen level greater than 4 µg/L. The undisputed utility of PSA is in monitoring patients after prostatic cancer treatment with surgery, radiotherapy, or antiandrogen therapy. After radical prostatectomy, prostate-specific antigen should decrease to undetectable levels, ie, below the lower limit of detection of the assay used.

Prostate cancer

In Canada, prostatic cancer ranks second in frequency to lung cancer in men. It contributes to 27 000 potential years of life lost compared with 129000 years for lung cancer annually. Miller has ranked PC fourth based on incidence and death and ninth based on premature mortality (because the incidence of detected prostatic cancer increased later in life, so life-span is not shortened the way it is by cancers that develop in younger people and because many prostatic cancers progress so slowly that deaths from other causes supervene). The prevalence of prostatic cancer increases with age, as evidenced at autopsy.

Posted in Prostate Gland

Preserving Sexual Function in Men. Part 2

Posted by admin on November 28th, 2009 No Comments

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, it does not eliminate retrograde ejaculation. Balloon dilation of the prostate is a new technique that uses coaxial high-pressure balloons to dilate the prostatic urethra to 75F to 90F. Several balloons and modes of placement have been described. We have experience with an endoscopically placed 75F balloon manufactured by the Advanced Surgical Intervention Company of San Clemente, Calif. This device produces satisfactory relief of symptoms and, in more than 2000 dilatations, there has been no incidence of impotence or retrograde ejaculation. This technique is most suited to male subjects with moderately sized prostates – the patients most concerned about the possibility of these complications (Figure 1).

Figure 1. Balloon Dilation of Prostate: A new technique dilates the prostatic urethra to 75F to 90F

Figure 1. Balloon Dilation of Prostate: A new technique dilates the prostatic urethra to 75F to 90F

Radical prostatectomy. Prostatic cancer is one of the most common malignancies in male subjects and the second leading cause of cancer death. Radical prostatectomy for disease localized to the prostate offers the patient a significant potential for cure. Unfortunately it has traditionally been associated with a very high incidence of incontinence and impotence. Many patients have rejected this option for treatment primarily because of these unacceptable sequelae.

Recently Walsh and associates have modified the technique of radical prostatectomy in order to preserve the nervi erigentes and maintain erectile potential. This has proven to be a more anatomically sound way of removing the prostate and has not only improved the preservation of potency to about 60% but also has virtually eliminated postoperative incontinence. Retrospective analysis of these patients indicates that it is feasibile to spare the nerve without compromising tumor excision. This new technique is encouraging more patients to take advantage of this curative treatment.

Surgery for bladder cancer. Radical cystectomy and urinary diversion is one of the options for treatment of localized, invasive transitional cell cancer of the bladder. This necessitates the removal of the prostate and always results in impotence. It is possible to apply the nerve-sparing techniques used in radical prostatectomies to this surgery. Care must be taken to exclude those patients likely to have local extension of tumor outside the bladder and lymph node involvement.” Experience with this form of cystectomy is still too recent to comment on long-term sequelae and local tumor control.

Retroperitoneal lymph node dissection. Testicular cancer is perhaps the most common solid tumor in young male patients. Its effect on fertility is devastating. There is evidence that patients with testicular malignancy have decreased fertility from birth, many having had cryptorchid testicles in infancy.

The occurrence of a testicular malignancy necessitates a unilateral orchiectomy for diagnosis and treatment and, in many instances, a retroperitoneal lymph node dissection. This procedure is quite effective in staging and treating testicular tumor with retroperitoneal node invasion and is often necessary before or after chemotherapy for residual disease. This dissection often injures the sympathetic nerves that traverse the area, which initiate emission. Thus retrograde ejaculation is a common sequela of this surgery. Early attempts at reducing the incidence of this complication originally limited the fields of dissection, but were not uniformly successful. More recently a true nerve-sparing technique has been described that involves the specific dissection and recognition of these nerves and their preservations. Early results with selected patients are encouraging.

Restoration of sexual function

This discussion would be incomplete without mention of techniques to restore sexual function. New advances in fertility may soon make in vitro fertilization available to male subjects with significantly reduced sperm numbers. Electroejaculation, OC-adrenergic medication, and sperm retrieval from the bladder can be effective in some patients with retrograde ejaculation or lack of emission but not, unfortunately, when they are the result of bladder neck resection in prostatic surgery.

The treatment of organic impotence has provided us with many techniques applicable to postsurgical impotence. Among these are the injection of papaverine and prostaglandins into the corpus cavernosum penis, some oral pharmacologic agents, such as yohimbine, and many vacuum devices designed to increase blood entrapment in the penis. In addition, there are many rigid, semirigid, and inflatable prosthetic penile implants that can be used. Patients should be made aware of these alternatives when discussing these new surgical procedures.

Discussion

The desire to preserve sexual function has increasingly affected patients’ acceptance of treatment modalities. In response to this concern, techniques have been modified and new surgical procedures devised. We have moved to early orchiopexy; we are exploring the advisability of early varicocele repair; and we have moved to more limited nerve-sparing procedures for some of the genitourinary malignancies. These nerve-sparing procedures are meticulous and not indicated in all patients. Disease grade and stage, as well as local variations in anatomy, have to be taken into consideration before embarking on such procedures.

It is important to realize that long-term follow up of nerve-sparing surgery is not yet available. We still do not know whether the new techniques will measure up to previous techniques in terms of long-term local control and distant metastasis. Balloon dilation of the prostate is an attractive alternative for the young male patient with symptoms of prostatism. It is capable of providing at least temporary relief of symptoms, can be repeated several times, and does not preclude subsequent surgery.

Patients are demanding and should have more say in selecting therapeutic alternatives. We must make them aware that we are still unsure whether long-term cancer control is as good with new as with old surgical techniques, and also that there are many ways to restore affected sexual function. In this way, we can assist them in making a truly informed decision. ■

Posted in Prostate Gland

Preserving Sexual Function in Men. Part 1

Posted by admin on November 28th, 2009 No Comments

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
• Voricocelectomy
• Prostatectomy

- Open prostatectomy

- Transurethral resection

- Balloon dilation of the prostate

- Radical prostatectomy
• Cystoprostatectomy
• Retroperitoneal lymph node dissection

Innate threats to function

Some boys and men have conditions that do not cause immediate problems but may pose a future threat to fertility. The trend is to be more aggressive in diagnosing such conditions.

Undescended testicle. Undescended testicles (cryptorchism) occurs commonly in male neonates but often resolves during the first 6 months of life. Testicles that have not descended by the time the patient is 9 months of age are unlikely to do so.

These testicles have an increased incidence of infertility later in life, as well as an increased incidence of testicular malignancy. Cancer of the testicle can, in turn, impair fertility, not only by the loss of one gonad but also by the therapy that may be required afterward. Chemotherapy inhibits spermatogenesis for a prolonged time and occasionally permanently. Retroperitoneal node dissection can interfere with emission. Timely surgery to position the testicles in the scrotum (orchiopexy) can significantly reduce the incidence of both these conditions.

Furthermore, there is growing evidence that the use of gonadotropic stimulating hormone (GnRH) instead of or in conjunction with orchiopexy can further improve fertility in these boys. We recommend that the testicles be brought down to the scrotum during the first 2 years of life. Although this will not completely eliminate the risk of malignancy, it will make the testicles more amenable to examination and could provide for early detection of any abnormality.

Varicoceles. Varicocele is the abnormal distention of scrotal veins (pampiniform plexus) owing to the congenital absence of venous valves, which permits the retrograde flow of venous blood to the testicle and slowly dilates these veins. Varicocele occurs in more than 10% of normal men and in probably the same percentage of adolescents.

Only in a few of these subjects is it associated with subfertility. Young adolescents normally present with a visible scrotal mass, which can be symptomatic. There is growing evidence that the adolescent varicocele affects future fertility in some instances. Kass has proposed that adolescents with a varicocele and ipsilateral smaller than normal testes, as well as those with bilateral varicoceles or abnormal results of semen analysis, should be offered repair to preserve their fertility potential. An abnormal response to an infusion of GnRH has been found in some infertile men with varicoceles. Kass and others believe that such a test could help us decide which teenagers with varicoceles are at risk of future subfertility and should be repaired. Ongoing studies are continuing to define the role of varicocelectomy in the young adult and child, but it seems that early varicocelectomy in selected cases can preserve fertility.

Posted in Prostate Gland

Treatments for Benign Prostatic Hyperplasia. Part 4

Posted by admin on November 28th, 2009 No Comments

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 available for Benign Prostatic Hyperplasia.

Complications. Mebust and associates reviewed mortality as well as intra-operative and postoperative complications in 3885 patients. The mortality from transurethral prostatic resection (TUPR) was 0.2%, with cardiovascular events being the predominant cause. The population at risk was elderly with multisystem disease. Intra-operative morbidity was reported at 7%. Hemorrhage, dilutional hyponatremia, arrhythmias, and extravasation were the most common complications. Eighteen percent of patients experienced postoperative complications, among which failure to void, hemorrhage, clot retention, and genitourinary infections were the most prominent.

Sexual function after prostatectomy

Sexual function after prostatectomy is an area of concern to many patients. The prevalence of postoperative impotence has been reported at between 5% and 31%. Retrograde ejaculation occurs in the majority of patients after transurethral prostatic resection. While this should not alter the sensation of orgasm and ejaculation, patients often find it distressing, and it can play a role in impotence.

Some studies suggest that there is no increase in sexual dysfunction when compared with other surgery in the elderly. The psychological affect of surgery involving the sexual organ, alteration of ejaculation, and the censure of sexual activity in the elderly may point to a cognitive, rather than a physiologic, event. The exact mechanism and incidence remain unknown.

Conclusion

Benign prostatic hyperplasia, both pathologically and clinically, increases with age. As the geriatric population expands, so will the medical and financial importance of this disease.

Transurethral prostatic resection is likely to remain the standard of care for the foreseeable future. It is a safe procedure, particularly when one considers the relatively high-risk population undergoing it. It is more effective than all other current and experimental forms of therapy by a wide margin. Efforts to reduce hospital stay will result in substantial savings and should be encouraged.

Alternative invasive therapies, such as balloon dilation and urethral stents, are currently unproven. The ideal techniques and optimal patient population have yet to be described. Current evidence would suggest a limited role for hormonal therapy, which is expensive and offers limited clinical benefit. More promising are the use of OC-adrenergic blockers to treat outlet obstruction and anticholinergics to treat irritative symptoms when obstruction is mild to moderate. ■

Posted in Prostate Gland

Treatments for Benign Prostatic Hyperplasia. Part 3

Posted by admin on November 28th, 2009 No Comments

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 rapidly cover with epithelium, making them useful even for patients with chronic infection. They have been placed successfully, without infectious complication, in catheter-dependent patients when vigorous antibiotic therapy was used before placement. With current stents, open surgery is required if removal becomes necessary. Unless the stent is placed correctly, there may be little improvement in symptoms, and incontinence may develop if sphincter function is impaired.
Several companies are actively searching for a material that can retain its shape and that could be resected with standard urologic equipment. At present, follow up is short, but results are sufficient to warrant further study.

Occult carcinoma

An important drawback of all therapies in which no tissue is removed is the potential failure to detect occult malignancy. Such malignancies are reported to occur in 22% of patients. Whether early detection of occult carcinoma has any effect on the clinical course of the disease is unknown. A thorough pretreatment digital rectal examination by an experienced physician is clearly important. There may be a role for the use of transrectal ultrasound or random prostatic biopsies, but they cannot be recommended on the evidence available to date.

Posted in Prostate Gland
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