Prostate cancer is third to lung and colon cancer as the cause of cancer-related deaths in American men. It is estimated that there will have been more than 28,000 deaths and 186,000 new cases in 2008 that will impose a significant burden on national health care costs. Chemoprevention aims to reduce both incidence and mortality through the use of agents to prevent, reverse, or delay the carcinogenic process. This study provides clinicians with information on some chemoprevention agents that have been considered to reduce prostate cancer risks, including 5-α-reductase inhibitors; statins (a class of compounds used to reduce cholesterol); NSAIDs; selenium; vitamins E and D; lycopene; allium vegetables (garlic, scallions, onions, chives, and leeks); soy/isoflavones; and green tea polyphenols. The evidence to support prostate cancer risk reduction benefits for each chemoprevention agent based on a review of the literature is provided.
Urologists are routinely faced with the dilemma of a persistently worrisome clinical picture for prostate cancer in patients who have undergone prior negative ultrasound-guided prostate biopsies. Indications for repeat biopsy include sustained or worsening of the findings that prompted the initial biopsy; various derivations of prostate-specific antigen; and the histology from the initial biopsy (ie, high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation is identified). Large prostate volume or inflammation can confound the decision to perform repeat biopsies. Repeat biopsies should include a combination of standard sextant, lateral, anterior apical, and possibly transition zone biopsies. Repeat biopsies should consist of at least 14 cores but may include more than 36 samples. In patients who are not at high risk for prostate cancer, more than two sets of repeat biopsies have a very low yield.
Elevated serum prostate-specific antigen (PSA) in the setting of acute or chronic bacterial prostatitis is common. Serum PSA, however, is much more variable in the setting of chronic nonbacterial prostatitis. Because elevated serum PSA is associated with prostate cancer and is used in screening programs for prostate cancer, patients with benign causes for elevation of serum PSA present a challenge. This article reviews the management of patients with elevated serum PSA and a diagnosis of chronic nonbacterial prostatitis.
Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are highly prevalent in older men and represent a substantial challenge to public health. Increasing epidemiologic evidence suggests that diabetes significantly increases the risks of BPH and LUTS. Plausible pathophysiologic mechanisms to potentially explain these associations include increased sympathetic tone, stimulation of prostate growth by insulin and related trophic factors, alterations in sex steroid hormone expression, and induction of systemic inflammation and oxidative stress. This article presents a comprehensive overview of the current understanding of clinical and epidemiologic research on diabetes and BPH/LUTS, describes hypothesized pathophysiologic mechanisms linking these conditions, and recommends future directions for research and clinical care.
Management of patients presenting with elevated serum prostate-specific antigen levels, or those with previously diagnosed prostate carcinoma, is very much dependent on the pathology report on needle biopsy or radical prostatectomy specimens obtained from these patients. In contrast to a diagnosis of benignity or high-grade prostatic intraepithelial neoplasia, a diagnosis of atypia on needle core biopsy is usually an indication for a repeat biopsy; however, it is important to understand that atypia and other related terms are not specific diagnoses. The pathology report on different prostate specimens with a diagnosis of carcinoma usually includes the Gleason grade and extent of carcinoma among other morphological prognostic and predictive factors. Understanding the significance of these morphological factors and how they are evaluated and incorporated into the pathology report, as well as newer developments in this field, can assist urologists in the interpretation of the pathological findings and ultimately lead to better clinical care.
Obesity has emerged as a global public health challenge. During the past 20 years, there has been a dramatic increase in obesity in the United States. In 2007, only one state had a prevalence of obesity less than 20%. In this growing epidemic of national concern is an emerging relationship between lower urinary tract symptoms (LUTS), benign prostatic hyperplasia (BPH), and obesity. BPH is the most common neoplastic condition afflicting men and constitutes a major factor impacting the health of the American male. Associations among obesity, physical inactivity, and BPH/LUTS resulting from epidemiological studies have not been explored via clinical trial methodology. A review of the available data appears to support a strong independent relationship between obesity and BPH/LUTS. This review also indicates that gene expression within the prostate varies with prostate size and can be affected by lifestyle modifications. Future studies may lead to office detection of a patient's particular polymorphisms, which may help guide individual treatment and lifestyle modifications that are more likely to succeed.
Chronic pelvic pain syndrome (CPPS) describes unexplained pelvic pain in men associated with irritative voiding symptoms, post-orgasmic pain, and/or pain located in the groin, genitalia, or perineum in the absence of bacterial infection. Many different etiologies of CPPS have been proposed, including roles for immunologic, neurologic, endocrine, and psychologic factors. This article examines one such factor—ejaculatory duct obstruction (EDO). Because EDO is correctable with relatively minor surgery, it should be considered by any clinician caring for a patient who reports symptoms of CPPS.
Treatment for men with lower urinary tract symptoms (LUTS) has developed into a "cascade" that escalates from watchful waiting through medical treatment to surgery. Self-management can help men to adopt lifestyle and behavioral modifications that will avoid or delay an escalation in treatment and reduce symptoms. Although many of these interventions are advised to men with LUTS, it is usually in a nonstandardized and unsystematic way. Recent work in this area has defined a self-management program for men with uncomplicated LUTS using formal methods and assessed its effectiveness in a randomized controlled trial. Self-management significantly reduced the frequency of escalation through the treatment cascade and reduced urinary symptoms (as effective as medication), suggesting that self-management could be considered as first-line treatment for men with LUTS.
The prostate-specific antigen (PSA) screening era has seen dramatic stage and age migration in patients with newly diagnosed prostate cancer. The average serum PSA level of newly diagnosed patients is about 6 ng/dL, and 60% of patients are diagnosed with clinical stage T1c disease. There is evidence that many low-grade and low-stage prostate cancers have a slow growth rate and protracted clinical course, with a very low threat of metastasis or death over a prolonged interval. Many men are also appropriately concerned about the impact of prostate cancer treatment on sexual and urinary function. Therefore, delaying therapy in favor of careful surveillance, with the expectation of delivering curative treatment upon evidence of progression, is an attractive concept. In this review, we discuss active surveillance, contrast it with watchful waiting, and define common inclusion criteria. We compare follow-up regimens and discuss indications and intervention outcomes after active surveillance. Finally, we support well-designed prospective clinical trials that evaluate active surveillance compared with immediate definitive treatment.
Recent evidence has indicated a significant link between benign prostatic hyperplasia (BPH) and sexual dysfunction (SD). Patients presenting with lower urinary tracts symptoms (LUTS) secondary to BPH should also be evaluated for comorbid SD, especially given the increasing basic science evidence demonstrating a common pathway for these two conditions. Therapy for BPH may exacerbate SD and should be selected carefully, with current data indicating a role for phosphodiesterase-5 inhibitors in the treatment of BPH. More long-term data are needed to determine the efficacy of the latest surgical therapies for BPH. The practice patterns of physicians differ slightly by specialty in the evaluation and treatment of patients with LUTS, but both groups significantly underestimate the prevalence of SD in this specific group of patients. Thus, sexual function should be a part of the urologic evaluation in patients with LUTS associated with BPH.
Erectile dysfunction (ED) is common after radical prostatectomy (RP). ED has a negative impact on health-related quality of life. Penile rehabilitation is defined as the use of any drug or device at or after RP to maximize erectile function recovery. The purpose of penile rehabilitation is the prevention of corpus cavernosal smooth muscle structural alterations not only to maximize the chances of a man having recovery of functional erections but also returning him to his preoperative erectile function level. Appreciating the value of penile rehabilitation requires understanding five concepts: the pathophysiology of ED after RP, cavernosal oxygenation, venous leak, and both the animal and human data supporting this strategy. This paper gives an overview of these factors and attempts to give a common-sense, practical guide to a rehabilitation program.
Tuberculosis remains an epidemic that affects one third of the world's population. The persistence of this disease is caused by a large pool of immune-compromised and lower socioeconomic populations. The advent of rapid transportation and migration has contributed to the persistence of this disease in developed and less developed nations. The emergence of drug-resistant strains has added an additional factor for the pervasiveness of tuberculosis. The genitourinary system is a primary target for hematogenous infections. This paper reviews the contemporary issues that affect the diagnosis and treatment of urinary tuberculosis.
Since the first transurethral resection of the prostate (TURP) was performed by Guyon at the Necker Hospital in Paris in 1901, this treatment modality has replaced open prostatectomy as the procedure of choice for more than 95% of patients. TURP has been used in surgical treatment of benign prostatic hyperplasia (BPH) and remains the gold standard treatment. Transurethral vapor resection of the prostate (TUVRP) and holmium laser enucleation of the prostate (HoLEP) are new treatment modalities for the treatment of BPH. Each procedure has its own advantages and disadvantages. Availability of instruments, surgical expertise, and specific indications for a particular procedure are of utmost importance for successful outcome, with minimal morbidity. TURP can be either monopolar or bipolar, using thin or thick loop. Bipolar TURP is associated with less bleeding and less chances of dilutional hyponatremia. TUVRP, using a thick wedge loop, causes vaporization and resection of the prostate, and is associated with less bleeding and short operative time. HoLEP is another effective alternative for the surgical treatment of BPH. The holmium laser possesses the ideal combination of cutting and coagulation; however, it has a learning curve.
Risk assessment is critical to providing appropriate counseling and treatment for patients diagnosed with prostate cancer. The three classic clinical parameters to determine risk have been clinical stage, biopsy grade, and prostate-specific antigen (PSA) level. More recently, the importance of PSA kinetics has been realized in the pretreatment and serologic relapse settings. This article reviews the use of PSA velocity and PSA doubling time in several clinical scenarios.
It has long been appreciated that a healthy lifestyle plays a critical role in cardiovascular health. It is now apparent that the same is true in the development of benign prostatic hyperplasia (BPH). Prospective cohort data originating from recently published randomized trials on the medical treatment of BPH and prevention of prostate cancer have been invaluable. A growing body of evidence suggests that exercise and the intake of specific macronutrients and micronutrients through regular diet play a beneficial role. Most strikingly, the magnitude of these effects is similar to medical therapies using α-blockers and 5-α-reductase inhibitors. The use of supplements for prostate disease is a multibillion dollar business in the United States, and supplements are more commonly prescribed than medical therapy in many countries. In contrast to consumption of micronutrients through regular diet, supplemental intake of micronutrients and phytotherapies currently lack evidence to support their efficacy.
Chronic prostatitis/chronic pelvic pain syndrome continues to pose a treatment challenge for urologists. Chronic prostatitis is a very common and poorly understood condition with significant impact on quality of life. In recent literature, studies have been conducted with various treatment modalities that include antibiotics, α-blockers, anti-inflammatory agents, and cognitive behavioral interventions such as biofeedback and psychotherapy. Patients have shown interest in phytotherapy as a treatment option with increasing frequency due to lack of efficacy of conventional therapies. However, very little is known about the efficacy of second- and third-line treatments, such as the use of herbal supplements. We review published literature regarding phytotherapy usage for chronic prostatitis. The treatments include Chinese herbs, green tea extract, zinc, cernitin pollen extract (bee pollen), quercetin, saw palmetto (Serenoa repens), and lycopene.
We are in the midst of a paradigm shift in the surgical management of benign prostatic hyperplasia (BPH). After decades of decline, there is a recent surge in the rate of BPH surgeries—largely represented by laser prostatectomy and office-based thermotherapies. In the United States, the number of transurethral resections of the prostate (TURP) continues to decline, now representing a minority of all procedures performed. We reflect on how such changes may affect resident training. We review education models that strive to maintain TURP proficiency amongst urology residents, despite fewer opportunities for training on live patients. Furthermore, we review how proposed changes in the structure of urology education might impact training in office-based procedures, such as prostate thermotherapy.
Radiotherapy has been successful in treating localized prostate cancer; however, a subset of patients will experience disease recurrence. Determination of the recurrence location must be made using pretreatment and posttreatment clinical variables, imaging, and postradiotherapy biopsy. Patients presumed to have local-only recurrence, optimal clinical risk factors, and an extended life expectancy may be considered for salvage local treatment. Current options include salvage surgery, cryoablation, and brachytherapy. Although they are associated with higher morbidity than primary therapy, salvage treatments can be effective and can still provide patients with a good oncologic and functional outcome. As these modalities continue to improve and patient selection is optimized, better results will evolve.
Chronic nonbacterial prostatitis, or urological chronic pelvic pain syndrome (UCPPS), remains a common and often challenging disorder to evaluate and treat. Employing a more holistic approach, including urological therapy, physical therapy, and psychosocial perspectives, may be more appropriate for most patients. Growing evidence supports the use of biofeedback, myofascial trigger point release, prescribed exercise regimens, relaxation techniques, and supportive counseling to treat men with UCPPS.
