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Article of the week: Men under 50 should not be discouraged from radical prostatectomy

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Andreas Becker discussing his paper.

If you only have time to read one article this week, it should be this one.

Functional and oncological outcomes of patients aged <50 years treated with radical prostatectomy for localised prostate cancer in a European population

Andreas Becker*†, Pierre Tennstedt*, Jens Hansen*, Quoc-Dien Trinh†, Luis Kluth‡, Nabil Atassi*, Thorsten Schlomm*, Georg Salomon*, Alexander Haese*, Lars Budaeus*, Uwe Michl*, Hans Heinzer*, Hartwig Huland*, Markus Graefen* and Thomas Steuber*

*Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, †Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada, and ‡Department of Urology, University-Hospital Hamburg-Eppendorf, Hamburg, Germany

Read the full article
OBJECTIVE

• To address the biochemical and functional outcomes after radical prostatectomy (RP) of men aged <50 years in a large European population.

PATIENTS AND METHODS

• Among 13 268 patients who underwent RP for clinically localised prostate cancer at our centre (1992–2011), 443 (3.3%) men aged <50 were identified.

• Biochemical recurrence (BCR) and functional outcomes (International Index of Erectile Function [IIEF-5], use of pads), were prospectively evaluated and compared between men aged <50 years and older patients.

RESULTS

• Men aged <50 years were more likely to harbour D’Amico low-risk (49.4 vs 34.9%, P < 0.001), organ-confined (82.6 vs 69.4%, P < 0.001) and low-grade tumours (Gleason score <7: 33.1 vs 28.7%, P < 0.001).

• Multivariate Cox regression analysis showed that age <50 years (hazard ratio 0.99; confidence interval 0.72–1.31; P = 0.9) was not a predictor of BCR.

• Urinary continence was more favourable in younger patients, resulting in continence rates of 97.4% vs 91.6% in most recent years (2009–2011) for patients aged <50 vs ≥50 years.

• After RP, a median IIEF-5 drop of 4 points in younger men vs 8 points in older patients was recorded (P < 0.001).

• Favourable recovery of urinary continence and erectile function in patients aged <50 years compared with their older counterparts was confirmed after multivariable adjustment.

CONCLUSION

• Men aged <50 years diagnosed with localised prostate cancer should not be discouraged from RP, as the postoperative rates of urinary incontinence and erectile dysfunction are low and probability of BCR-free survival at 2 and 5 years is high.

 

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Editorial: Radical prostatectomy at young age

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Becker et al. [1] investigated a large sample of young patients (aged <50 years) who underwent radical prostatectomy during a 20-year period in a high-volume European centre. In this study [1], men aged <50 years had a significantly more favourable functional outcome (continence rates [0–1 pads] 97% vs 92%; International Index of Erectile Function [IIEF] score drop of 4 vs 8 points), compared with their older counterparts. Biochemical tumour control was higher in younger patients in univariate (5-year rates 81% vs 70%) but not in multivariate analysis.

In studies in the pre-PSA era, young age at prostate cancer diagnosis was often associated with adverse tumour-related outcome [2]. Possibly, the disadvantage of younger patients was attributable to rapidly growing high-grade tumours causing symptoms at a young age in the absence of a dilution by favourable early detected low-grade cancers. In contemporary patients, the opposite is observed [1]. As the impact of age vanished after controlling for tumour-related prognostic factors reflecting the presence of more favourable disease criteria in younger men, it may be considered likely that PSA-based early detection enriched favourable parameters in the younger subgroup. Altogether, prostate cancer biology is probably not meaningfully associated with age. Outcome differences, even in randomised trials [3, 4], are rather caused by age-related differences in the approach to prostate cancer diagnostics and early detection than in actual biological differences.

The relative favourable functional outcome in younger patients [1] supports early curative treatment in this population. Currently available active surveillance studies have very limited follow-up and were performed mainly in elderly patients with significant comorbidity [5]. Currently, in Germany the further life expectancy in men aged 50 years is ≈30 years [6]. In a contemporary active surveillance study, narrowly half of patients received active treatment within 10 years [5]. Therefore, most men starting active surveillance at an age of 50 years will subsequently receive active treatment. This treatment will then be performed at a greater age where the chances for satisfactory functional recovery are less favourable.

The inferior tumour control rates in patients receiving robot-assisted surgery is another remarkable finding of this study (hazard ratio 1.4, 95% CI 0.99–1.9, P = 0.06 in the multivariate analysis). Although the significance level was narrowly failed, this observation cannot be ignored. It was accompanied by an increased continence recovery rate after robot-assisted surgery suggesting that it may probably not be attributed to the learning curve. Less radical removal of the prostate with more sparing of neurovascular structures and bladder neck might be a conceivable explanation of this phenomenon. In this study [1], the prognostic impact of robot-assisted approach was in a similar range as a positive surgical margin (hazard ratio 1.5, 95% CI 1.4–1.7).

Current clinical guidelines discourage prostate cancer screening in average-risk men aged <50 years [7]. It remains to be seen in which degree these recommendations will affect clinical practice and outcome parameters in this age group in the years ahead.

Read the full article

Manfred P. Wirth and Michael Froehner
Department of Urology, University Hospital ‘Carl Gustav Carus’, Dresden University of Technology, Dresden, Germany

References

  1. Becker A, Tennstedt P, Hansen J et al. Functional and oncological outcomes of patients younger than 50 years treated with radical prostatectomy for localized prostate cancer in a European population. BJU Int 2014; 114: 38–45
  2. Parker CC, Gospodarowicz M, Warde P. Does age influence the behaviour of localized prostate cancer? BJU Int 2001; 87: 629–637
  3. Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011; 364: 1708–1717
  4. Froehner M, Wirth MP. Early prostate cancer – treat or watch? N Engl J Med 2011; 365: 568
  5. Selvadurai ED, Singhera M, Thomas K et al. Medium-term outcomes of active surveillance for localised prostate cancer. Eur Urol 2013; 64: 981–987
  6. Statistisches Bundesamt. Periodensterbetafeln für Deutschland 1871/1881 bis 2008/2010 [Period death tables for Germany 1871/1881 bis 2008/2010]. Wiesbaden 2012. Available at: https://www.destatis.de/DE/Publikationen/Thematisch/Bevoelkerung/Bevoelkerungsbewegung/PeriodensterbetafelnPDF_5126202.pdf?__blob=publicationFile [Website in German]. Accessed 12 July 2013.
  7. Qaseem A, Barry MJ, Denberg TD, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2013; 158: 761–769
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Video: RP for younger men – low risk and high survival rate

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Functional and oncological outcomes of patients aged <50 years treated with radical prostatectomy for localised prostate cancer in a European population

Andreas Becker*†, Pierre Tennstedt*, Jens Hansen*, Quoc-Dien Trinh†, Luis Kluth‡, Nabil Atassi*, Thorsten Schlomm*, Georg Salomon*, Alexander Haese*, Lars Budaeus*, Uwe Michl*, Hans Heinzer*, Hartwig Huland*, Markus Graefen* and Thomas Steuber*

*Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, †Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada, and ‡Department of Urology, University-Hospital Hamburg-Eppendorf, Hamburg, Germany

Read the full article
OBJECTIVE

• To address the biochemical and functional outcomes after radical prostatectomy (RP) of men aged <50 years in a large European population.

PATIENTS AND METHODS

• Among 13 268 patients who underwent RP for clinically localised prostate cancer at our centre (1992–2011), 443 (3.3%) men aged <50 were identified.

• Biochemical recurrence (BCR) and functional outcomes (International Index of Erectile Function [IIEF-5], use of pads), were prospectively evaluated and compared between men aged <50 years and older patients.

RESULTS

• Men aged <50 years were more likely to harbour D’Amico low-risk (49.4 vs 34.9%, P < 0.001), organ-confined (82.6 vs 69.4%, P < 0.001) and low-grade tumours (Gleason score <7: 33.1 vs 28.7%, P < 0.001).

• Multivariate Cox regression analysis showed that age <50 years (hazard ratio 0.99; confidence interval 0.72–1.31; P = 0.9) was not a predictor of BCR.

• Urinary continence was more favourable in younger patients, resulting in continence rates of 97.4% vs 91.6% in most recent years (2009–2011) for patients aged <50 vs ≥50 years.

• After RP, a median IIEF-5 drop of 4 points in younger men vs 8 points in older patients was recorded (P < 0.001).

• Favourable recovery of urinary continence and erectile function in patients aged <50 years compared with their older counterparts was confirmed after multivariable adjustment.

CONCLUSION

• Men aged <50 years diagnosed with localised prostate cancer should not be discouraged from RP, as the postoperative rates of urinary incontinence and erectile dysfunction are low and probability of BCR-free survival at 2 and 5 years is high.

Read more articles of the week

Article of the week: Mortality after cystectomy is related to hospital volume

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Nielsen and Dr. Milowsky discussing their paper.

If you only have time to read one article this week, it should be this one.

Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base

Matthew E. Nielsen*†‡, Katherine Mallin§, Mark A. Weaver, Bryan Palis§, Andrew Stewart§, David P. Winchester§ and Matthew I. Milowsky*,**

*University of North Carolina Lineberger Comprehensive Cancer Center, †Department of Urology, and Divisions of General Medicine and Clinical Epidemiology and **Hematology and Oncology, University of North Carolina School Something like this?of Medicine, ‡Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, and §American College of Surgeons, National Cancer Data Base, Chicago, IL, USA

This research was presented at the Society of Urologic Oncology 2012 Annual Meeting, 29 November 2012, Bethesda, MD, USA

Read the full article
OBJECTIVE

To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days.

PATIENTS AND METHODS

The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35 055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals.

Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10–19 procedures; high-volume hospital: ≥20 procedures).

Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling.

RESULTS

Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively.

Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3–1.9), and 1.2 (1.0–1.4), respectively.

CONCLUSIONS

A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata.

The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes.

Read more articles of the week

 

Editorial: High hospital volume reduces mortality after cystectomy

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In the current issue of BJUI, Nielsen et al. [1] assessed the role of hospital characteristics on the risk of short-term mortality in a contemporary cohort of patients with bladder cancer treated with radical cystectomy (RC) representing the USA population. In their investigation, the authors evaluated >35 000 undergoing RC included within the National Cancer Database. Interestingly, they showed that hospital volume represents an independent predictor of both 30- and 90-day mortality. Several studies already explored the association between hospital characteristics (i.e., hospital volume) and short- and long-term postoperative outcomes, e.g. complication, blood transfusion, readmission, and mortality rates after RC [2-5]. Although this topic has already been broadly investigated, the current study was able to determine the 90-day mortality rates conditional on survival to 30 days after RC.

From a clinical standpoint, the authors report several relevant findings. First, hospital volume represented an independent predictor of 90-day mortality after RC [1]. Particularly, patients treated in centres performing an average of >20 RC/year had significantly lower mortality rates compared with those undergoing RC in smaller volume hospitals. However, it should be noted that the magnitude of the effect was substantially greater when evaluating the 30-day period as compared with 90 days after RC. This observation leads to clinically relevant considerations. Indeed, it might be speculated that the better quality of care generally provided in high-volume tertiary referral centres has a substantial impact on perioperative outcomes and mortality. However, this effect manifests itself mainly in the immediate period after RC. This is consistent with previous studies evaluating the impact of hospital volume on perioperative outcomes in inpatient cohorts [4, 5]. For example, Trinh et al. [3] showed that this parameter was significantly associated with the risk of dying in the perioperative period when a complication occurred. In this context, tertiary referral centres might be better equipped to assist patients in the postoperative period and eventually treat them in a timely fashion [4]. Particularly, better processes of care, e.g. preoperative patient evaluation, invasive monitoring, and perioperative consultations with critical care and other units, might be at least in part responsible for this phenomenon [4]. These observations justify the referral to high-volume centres when a major surgical procedure is planned [3, 4]. On the other hand, the quality of the assistance received during hospitalisation might have a limited impact on postoperative outcomes after hospital discharge. Consequently, these findings might be used to advocate better home care in order to improve patient management after hospital discharge and, in turn, reduce the risk of perioperative morbidity and mortality.

Second, it should be noted that a substantial proportion of patients had died by the 3-month follow-up (7.2%). Moreover, up to 5% of patients who survived at 1 month after RC died in the following 2 months. These observations are consistent with previous studies and highlight the need for better perioperative patient management [1, 3, 5, 6]. Additionally, these sobering figures should be used to advocate better patient selection in order to spare the potential RC-related complications in frail patients, where alternative and less invasive treatment options might be considered.

Concluding, the study by Nielsen et al. [1] further demonstrates that patients with bladder cancer undergoing RC have a non-negligible risk of perioperative mortality at 30- and 90-days after RC. Patients treated at higher volume centres (≥20 procedures/year) experience better perioperative outcomes compared with their counterparts undergoing RC at lower volume institutions (<10 procedures/year). However, the effect of hospital volume on the risk of perioperative mortality is considerably greater in the early period after RC. Consequently, substantive efforts should be made to improve postoperative patient care even after hospital discharge.

Read the full article

Giorgio Gandaglia*†, Pierre I. Karakiewicz†, Quoc-Dien Trinh‡ and Maxine Sun*

*Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Centre, Canada, †Urological Research Institute, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy, and ‡Center for Surgery and Public Health, Division of Urologic Surgery, Brigham and Women’s Hospital, Boston, MA, USA

References

  1. Nielsen ME, Mallin K, Weaver MA et al. Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the national cancer database. BJU Int 2014; 114: 46–55
  2. Kulkarni GS, Urbach DR, Austin PC, Fleshner NE, Laupacis A. Higher surgeon and hospital volume improves long-term survival after radical cystectomy. Cancer 2013; 119: 3546–3554
  3. Trinh VQ, Trinh QD, Tian Z et al. In-hospital mortality and failure-to-rescue rates after radical cystectomy. BJU Int 2013; 112: E20–27
  4. Sun M, Ravi P, Karakiewicz PI et al. Is there a relationship between leapfrog volume thresholds and perioperative outcomes after radical cystectomy? Urol Oncol 2014; 32: 27 e7–13
  5. Kim SP, Boorjian SA, Shah ND et al. Contemporary trends of in-hospital complications and mortality for radical cystectomy. BJU Int 2012; 110: 1163–1168
  6. Gandaglia G, Popa I, Abdollah F et al. The effect of neoadjuvant chemotherapy on perioperative outcomes in patients who have bladder cancer treated with radical cystectomy: a population-based study. Eur Urol 2014; (in press) doi: 10.1016/j.eururo.2014.01.014

 

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Video: Hospital volume and conditional 90-day post-cystectomy mortality

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Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base

Matthew E. Nielsen*†‡, Katherine Mallin§, Mark A. Weaver, Bryan Palis§, Andrew Stewart§, David P. Winchester§ and Matthew I. Milowsky*,**

*University of North Carolina Lineberger Comprehensive Cancer Center, †Department of Urology, and Divisions of General Medicine and Clinical Epidemiology and **Hematology and Oncology, University of North Carolina School Something like this?of Medicine, ‡Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, and §American College of Surgeons, National Cancer Data Base, Chicago, IL, USA

This research was presented at the Society of Urologic Oncology 2012 Annual Meeting, 29 November 2012, Bethesda, MD, USA

Read the full article
OBJECTIVE

To examine the association of hospital volume and 90-day mortality after cystectomy, conditional on survival for 30 days.

PATIENTS AND METHODS

The National Cancer Data Base was used to evaluate 30- and 90-day mortality for 35 055 patients who underwent cystectomy for bladder cancer at one of 1118 hospitals.

Patient data were aggregated into hospital volume categories based on the mean annual number of procedures (low-volume hospital: <10 procedures; intermediate-volume hospital: 10–19 procedures; high-volume hospital: ≥20 procedures).

Associations between mortality and clinical, demographic and hospital characteristics were analysed using hierarchical logistic regression models. To assess the association between hospital volume and 90-day mortality independently of shorter-term mortality, 90-day mortality conditional on 30-day survival was assessed in the multivariate modelling.

RESULTS

Unadjusted 30- and 90-day mortality rates were 2.7 and 7.2% overall, 1.9 and 5.7% among high-volume hospitals, and 3.2 and 8.0% among low-volume hospitals, respectively.

Compared with high-volume hospitals, the adjusted risks among low-volume hospitals (odds ratio [95% CI]) of 30- and 90-day mortality, conditional on having survived for 30 days, from the hierarchical models were 1.5 (1.3–1.9), and 1.2 (1.0–1.4), respectively.

CONCLUSIONS

A low hospital volume was associated with greater 30- and 90-day mortality. These data support the need for further research to better understand the relatively high mortality rates seen between 30 and 90 days, which are high and less variable across hospital volume strata.

The stronger association between volume and 30-day mortality suggests that quality-reporting efforts should focus on shorter-term outcomes.

Read more articles of the week

 

Article of the week: A protocol for transperineal sector biopsies of the prostate

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Indications, results and safety profile of transperineal sector biopsies (TPSB) of the prostate: a single centre experience of 634 cases

Lona Vyas, Peter Acher, Janette Kinsella, Ben Challacombe, Richard T.M. Chang, Paul Sturch, Declan Cahill, Ashish Chandra and Richard Popert

The Urology Centre, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Read the full article
OBJECTIVE

• To describe a protocol for transperineal sector biopsies (TPSB) of the prostate and present the clinical experience of this technique in a UK population.

PATIENTS AND METHODS

• A retrospective review of a single-centre experience of TPSB approach was undertaken that preferentially, but not exclusively, targeted the peripheral zone of the prostate with 24–38 cores using a ‘sector plan’. Procedures were carried out under general anaesthetic in most patients.

• Between January 2007 and August 2011, 634 consecutive patients underwent TPSB for the following indications: prior negative transrectal biopsy (TRB; 174 men); primary biopsy in men at risk of sepsis (153); further evaluation after low-risk disease diagnosed based on a 12-core TRB (307).

RESULTS

• Prostate cancer was found in 36% of men after a negative TRB; 17% of these had disease solely in anterior sectors.

• As a primary diagnostic strategy, prostate cancer was diagnosed in 54% of men (median PSA level was 7.4 ng/mL).

• Of men with Gleason 3+3 disease on TRB, 29% were upgraded and went on to have radical treatment.

• Postoperative urinary retention occurred in 11 (1.7%) men, two secondary to clots. Per-urethral bleeding requiring hospital stay occurred in two men. There were no cases of urosepsis.

CONCLUSIONS

• TPSB of the prostate has a role in defining disease previously missed or under-diagnosed by TRB. The procedure has low morbidity.

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Editorial: Is zero sepsis alone enough to justify transperineal prostate biopsy?

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The landscape of infectious complications after TRUS-guided biopsy of the prostate has changed dramatically. While sepsis after TRUS-guided prostate biopsy has always been a concern for urologists performing this very common procedure, in the past couple of years a number of factors have added to these pre-existing concerns for urologists and patients alike.

First, key papers have reported the true incidence of sepsis and hospital re-admission after TRUS biopsy and have shown that these rates are increasing. Loeb et al. [1] reported that the 30-day re-admission rate in a Surveillance, Epidemiology and End Results (SEER)-Medicare population was 6.9% and that this rate is increasing. Nam et al. [2] similarly reported a 3.5-fold increase in hospital admissions after prostate biopsy in the previous 10 years, principally attributable to infection-related complications. These reports have been replicated around the world and there is consensus that this is a growing problem.

Second, there are increasing concerns about the emergence of resistant organisms, in particular, extended spectrum beta lactamase (ESBL), in regions where antibiotic use has contributed to the emergence of these strains [3]. Media attention has focused on this issue and has led to increased concerns among urologists and patients alike. It has also led to a requirement for extra precautions when assessing patients for prostate biopsy such that in some regions, rectal swabs are being taken to identify ESBL-carriers ahead of time. In a contemporary series, Taylor et al. [4] report that 19% of men undergoing transrectal prostate biopsy in Canada carry ciprofloxacin-resistant coliforms in rectal swabs. The thought of passing a needle through this flora into the prostate is somewhat disturbing; rectal swabs may become mandatory when offering a TRUS-guided biopsy to any patient and should absolutely be taken if planning a TRUS biopsy in someone who has travelled to South-East Asia in the preceding 6 months.

The Bloomberg News, in a well-researched report into antibiotic use in India and the emergence of resistant strains of Escherichia coli, reported some startling statistics about the overuse of antibiotics in that country, and described how the ‘perfect storm’ of antibiotic overuse, poverty and poor sanitation (half of the country’s 1.2 billion residents defaecate in the open), is contributing to the emergence of superbugs colonizing the gut of dwellers and visitors to India [5]. It is clear that even walking through a puddle in New Delhi puts a visitor at high risk of harbouring ESBL organisms in the rectum for many months after.

In this month’s BJUI, Vyas et al. [6] describe a consecutive series of 634 patients undergoing prostate biopsy at Guy’s Hospital in London using a transperineal template-guided approach, and report a sepsis rate of zero. They also report other notable factors including a 36% cancer detection rate in men who had previously undergone transrectal prostate biopsy with no evidence of malignancy and, in men on active surveillance for Gleason 6 prostate cancer, they observed upgrading to Gleason ≥7 cancer in 29% of cases after immediate re-staging biopsy using a transperineal approach. An even larger contemporary study from Pepe et al. [7] reports zero sepsis in a consecutive series of 3000 men undergoing transperineal prostate biopsy.

It is quite impossible to imagine such large series of prostate biopsies with no episodes of sepsis if performed using a transrectal approach. The documented increasing levels of ESBL and high levels of asymptomatic gut colonization, especially for those resident or travelling through South-East Asia, mean that adequate risk assessment and counselling of patients before TRUS biopsy is more important than ever before. A careful history regarding recent antibiotic use is also essential as previous recent use of quinolones is also a risk factor for infection after a transrectal biopsy [8].

While widespread adoption of a transperineal approach to prostate biopsy would have considerable resource and logistic issues, and inevitably would not be accepted by all urologists, the rising rate of infectious complications and of resistant organisms colonizing the rectum may mean that continuing with a transrectal approach becomes too risky and therefore unacceptable to patients and clinicians alike. While a transperineal approach also appears to add value in terms of more accurate staging and also facilitates the emerging interest in MRI fusion-guided biopsies and focal therapy, zero sepsis alone may be enough to convince many that a transrectal approach should no longer be preferred.

Read the full article

Declan G. Murphy*†, Mahesha Weerakoon† and Jeremy Grummet‡

*Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, †Australian Prostate Cancer Research Centre, Epworth Richmond Hospital, and ‡Department of Urology, The Alfred Hospital, Melbourne, VIC, Australia

References

  1. Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: data from SEER-Medicare. J Urol 2011; 186: 1830–1834
  2. Nam RK, Saskin R, Lee Y et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010; 183: 963–968
  3. Williamson DA, Masters J, Freeman J, Roberts S. Travel-associated extended-spectrum beta-lactamase-producing Escherichia coli bloodstream infection following transrectal ultrasound-guided prostate biopsy. BJU Int 2012; 109: E21–22
  4. Taylor S, Margolick J, Abughosh Z et al. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int 2013; 111: 946–953
  5. Gale JN, Narayan A. Drug-defying germs from India speed post-antibiotic era. 2012; Available at: https://www.bloomberg.com/news/2012-05-07/drug-defying-germs-from-india-speed-post-antibiotic-era.html. Accessed June 2014
  7. Pepe PA, Aragona F. Morbidity after transperineal prostate biopsy in 3000 patients undergoing 12 vs 18 vs more than 24 needle cores. Urology 2013; 81: 1142–1146
  8. Patel U, Dasgupta P, Amoroso P, Challacombe B, Pilcher J, Kirby R. Infection after transrectal ultrasonography-guided prostate biopsy: increased relative risks after recent international travel or antibiotic use. BJU Int 2012; 109: 1781–1785

 

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Article of the month – Good vibrations: better erectile function with penile vibratory stimulation

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by prominent members of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Fode discussing his paper.

If you only have time to read one article this week, it should be this one.

Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial

Mikkel Fode*, Michael Borre†, Dana A. Ohl‡, Jonas Lichtbach§ and Jens Sønksen*

*Department of Urology, Herlev University Hospital, Herlev, †Department of Urology, Aarhus University Hospital, Aarhus, Denmark, ‡Department of Urology, University of Michigan, Ann Arbor, MI, USA, and §Department of Physiotherapy, Herlev University Hospital, Herlev, Denmark

Read the full article
OBJECTIVE

• To examine the effect of penile vibratory stimulation (PVS) in the preservation and restoration of erectile function and urinary continence in conjunction with nerve-sparing radical prostatectomy (RP).

PATIENTS AND METHODS

• The present study was conducted between July 2010 and March 2013 as a randomized prospective trial at two university hospitals which we already determined with the physiotherapy system with the professional and affordable physiotherapy merrylands  has to offer for the trials. Eligible participants were continent men with an International Index of Erectile Function-5 (IIEF-5) score of at least 18, scheduled to undergo nerve-sparing RP.

• Patients were randomized to a PVS group or a control group. Patients in the PVS group were instructed in using a PVS device (FERTI CARE® vibrator).

• Stimulation was performed at the frenulum once daily by the patients in their own homes for at least 1 week before surgery. After catheter removal, daily PVS was re-initiated for a period of 6 weeks.

• Participants were evaluated at 3, 6 and 12 months after surgery with the IIEF-5 questionnaire and questions regarding urinary bother. Patients using up to one pad daily for security reasons only were considered continent. The study was registered at https://clinicaltrials.gov/ (NCT01067261).

RESULTS

• Data from 68 patients were available for analyses (30 patients randomized to PVS and 38 patients randomized to the control group).

• The IIEF-5 score was highest in the PVS group at all time points after surgery with a median score of 18 vs 7.5 in the control group at 12 months (P = 0.09), but the difference only reached borderline significance.

• At 12 months, 16/30 (53%) patients in the PVS group had reached an IIEF-5 score of at least 18, while this was the case for 12/38 (32%) patients in the control group (P = 0.07).

• There were no significant differences in the proportions of continent patients between groups at 3, 6 or 12 months. At 12 months 90% of the PVS patients were continent, while 94.7% of the control patients were continent (P = 0.46).

CONCLUSION

• The present study did not document a significant effect of PVS. However, the method proved to be acceptable for most patients and there was a trend towards better erectile function with PVS. More studies are needed to explore this possible effect further.

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Editorial: Penile vibratory stimulation (PVS) a novel approach for penile rehabilitation post nerve sparing radical prostatectomy

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The reported incidence of erectile dysfunction (ED) after nerve-sparing radical prostatectomy (NS-RP) varies in the literature from 30 to 80% [1]. This can be explained by the state of neuropraxia which affects the cavernosal nerves, even if the nerves are anatomically intact. During this period there is a lack of nocturnal tumescence which leads to tissue hypoxia and ischaemic damage to the cavernosal smooth muscles leading to smooth muscle necrosis and fibrosis, which in turn causes veno-occlusive dysfunction (VOD). A study by Mulhall et al. [2] showed that, at 12 months after NS-RP, 50% of patients will have VOD and ED. The role of penile rehabilitation, therefore, is to maintain adequate tissue oxygenation until the cavernosal nerves recover with the return of the spontaneous nocturnal tumescence; thus, penile rehabilitation should not be confused with ED treatment. If you see yourself as religious, addiction may make you feel guilty or get you to feel isolated among your friends at your religious organization. A spiritual Christian rehab center in Orlando may be the right choice for you. Not only do you get to meet like-minded people to share your experiences in your journey to sobriety, but the process may also help you to rediscover your faith in God. Legacy Healing Center Tampa offer programs that make spiritual guidance an important part of every type of addiction treatment. Orange County law enforcement has taken steps to make sure the drugs are not as easily available as they once were. This has helped manage Orlando’s drug problem and kept it from turning worse. As important as prevention is to saving lives, however, to the hundreds who are already addicted, rehab is what helps. If you are religious or spiritual, faith-based drug rehab can be the answer to the challenges that you face. It’s important to remember that faith-based rehab only works well for those who are deeply spiritual or religious. Trying faith-based rehab when you are ambivalent about religion can work against you. You may find that you aren’t able to accept what you’re asked to practice, and you may find yourself rebelling. It’s important to choose a treatment approach that you can go along with in good conscience.

Several lines of treatment, including phosphodiesterase 5 inhibitors, intracavernous injection of alprostadil and vacuum pump therapy, have been used in penile rehabilitation but an agreed rehabilitation programme in terms of agents used, timing and duration of therapy does not yet exist [1].

The present study by Fode et al. [3] reports a novel approach to penile rehabilitation using penile vibratory stimulation (PVS). The study looked into the effect of PVS on postoperative erection and continence. The Ferticare® vibrator (Fig. 1) was used at an amplitude of 2 mm and a vibration frequency of 100 Hz and applied to the frenulum once daily, with a sequence consisting of 10 s of stimulation followed by a 10-s rest and repeated 10 times.

The results showed a trend towards better erection in the PVS group (n = 30) compared with the control group (n = 38) as evidenced by the higher International Index of Erectile Function (IIEF) score, but the difference was not significant (P = 0.09). After 1 year, 16 patients (53%) in the PVS group had an IIEF score ≥18 compared with 12 (32%) patients in the control group (P = 0.07). The results did not show any effect of treatment on continence; at 12 months, 90% of the PVS group achieved continence compared with 94.7% of the control group (P = 0.46), although the PVS group had a significantly higher preoperative LUTS score which may explain the results.

The theory postulated is that application of PVS activates the parasympathetic erectile spinal centre (S2–S4), which in turn leads to activation of the cavernosal nerves, enhancing the healing process, and recovery from neuropraxia and restoration of spontaneous erections. Also this would lead to stimulation of the somatic S2–S4 spinal centre, which controls the pelvic floor muscles via the pudendal nerve, leading to the recovery of continence. Although this has been shown in patients with spinal cord injury as the authors mentioned; this may not be the case in post NS-RP with the nerves in a state of neurapraxia, whereas in patients with spinal cord injury the nerves are intact. It would have been of great value to conduct neurophysiological tests on these patients to demonstrate that, despite the cavernosal nerves being in a state of neurapraxia, nerve activity in response to PVS was actually present.

The rehabilitation protocol used in the present study started early but only continued for 6 weeks postoperatively. Studies have shown that the potential recovery time of erectile function after NS-RP is 6–36 months, with the majority recovering within 12–24 months [1,4]. The results might have shown statistical significance in favour of PVS, had treatment continued for a longer period. Starting PVS treatment in the early postoperative period may not be suitable in all patients; in this study six out of 36 patients (16.6%) were non-compliant with the protocol; four had prolonged catheterization and two experienced pain. Furthermore, neurophysiological testing is required to show that in the early postoperative period the cavernosal nerves are actually intact and therefore respond to PVS.

Although the results of the present study did not reach significance, they are encouraging, as there was a trend in favour of treatment with regard to erectile function. Further studies involving larger numbers of patients are warranted to investigate this new line of rehabilitation.

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Amr Abdel Raheem*† and David Ralph†
*Andrology Department, Cairo University Hospital, Cairo, Egypt, and †St. Peter’s Andrology Centre, Institute of Urology, London, UK

References

  1. Mulhall JP, Bivalacqua TJ, Becher EF. Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy. J Sex Med 2013; 10: 195–203
  2. Mulhall JP, Slovick R, Hotaling J et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol 2002; 167: 1371–5
  3. Fode M, Borre M, Ohl D, Lichtbach J, Sønksen J. Penile vibratory stimulation in the recovery of urinary continence and erectile function after nerve-sparing radical prostatectomy: a randomized, controlled trial. BJU Int 2014; 114: 111–7
  4. Rabbani F, Schiff J, Piecuch M et al. Time course of recovery of erectile function after radical retropubic prostatectomy: does anyone recover after 2 years? J Sex Med 2010; 7: 3984–90
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