Prostate cancer in renal transplant recipients

ABSTRACT As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immuno-suppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Prostate cancer in renal transplant recipients.

As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immunosuppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Peyronie's Disease: AUA Guideline.

PURPOSE: The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of Peyronie's disease. MATERIALS AND METHODS: A systematic review of the literature using the PubMed®, EMBASE® and Cochrane databases (search dates 1/1/1965 to 1/26/15) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of PD. The review yielded an evidence base of 303 articles after application of inclusion/exclusion criteria. RESULTS: The systematic review was used to create guideline statements regarding treatment of PD. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional consensus statements related to the diagnosis of PD are provided as Clinical Principles and Expert Opinions due to insufficient published evidence. CONCLUSIONS: There is a continually expanding literature on PD; the Panel notes that this document constitutes a clinical strategy and is not intended to be interpreted rigidly. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment. As the science relevant to PD evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Erectile dysfunction in robotic radical prostatectomy: Outcomes and management.

Robot-assisted laparoscopic prostatectomy (RALP) has emerged as the most common treatment for localized prostate cancer. With improved surgical precision, RALP has produced hope of improved potency rates, especially with the advent of nerve-sparing and other modified techniques. However, erectile dysfunction (ED) remains a significant problem for many men regardless of surgical technique. To identify the functional outcomes of robotic versus open and laparoscopic techniques, new robotic surgical techniques and current treatment options of ED following RALP. A Medline search was performed in March 2014 to identify studies comparing RALP with open retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy, modified RALP techniques and treatment options and management for ED following radical prostatectomy. RALP demonstrates adequate potency rates without compromising oncologic benefit, with observed benefit for potency rates compared with RRP. Additionally, specific surgical technical modifications appear to provide benefit over traditional RALP. Phosphodiesterase-5 inhibitors (PDE5I) demonstrate benefit for ED treatment compared with placebo. However, long-term benefit is often lost after use. Other therapies have been less extensively studied. Additionally, correct patient identification is important for greatest clinical benefit. RALP appears to provide beneficial potency rates compared with RRP; however, these effects are most pronounced at high-volume centers with experienced surgeons. No optimal rehabilitation program with PDE5Is has been identified based on current data. Additionally, vacuum erection devices, intracavernosal injections and other techniques have not been well validated for post RALP ED treatment.

Long-term infection outcomes of 3-piece antibiotic impregnated penile prostheses used in replacement implant surgery.

PURPOSE: Patients who undergo device revision surgery are at higher risk for infection than virgin implant recipients. The revision rate due to virgin implant infection is statistically significantly lower for minocycline/rifampin impregnated than for nonimpregnated inflatable penile prostheses. We determined whether the frequency of infection revision events after device replacement surgery would also be lower for minocycline/rifampin impregnated inflatable penile prostheses. MATERIALS AND METHODS: Patient information forms voluntarily submitted to AMS® after replacement inflatable penile prosthesis implantation between 2001 and 2007 were retrospectively reviewed to compare secondary infection related revision events for antibiotic impregnated vs nonimpregnated implants. Only men who received an inflatable penile prosthesis at a first recorded operation to replace a previously implanted penile prosthesis were included in the study. Life table survival analysis was done between the groups to compare infection related events resulting in a second surgical revision after replacement implantation. Survival function extrapolation was based on parametric analysis using the Weibull distribution model. RESULTS: On life table survival analysis secondary revision due to infection was significantly less common in the minocycline/rifampin impregnated group than in the nonimpregnated group (log rank p = 0.0252). At up to 6.6 years of followup 2.5% of 9,300 men with vs 3.7% of 1,764 without an impregnated device underwent secondary revision due to infection. CONCLUSIONS: This long-term device survival analysis provides clinical evidence of a significant decrease in infection related secondary revisions using minocycline/rifampin impregnated prostheses vs nonimpregnated inflatable penile prostheses at replacement implant surgery.

Prognostic utility of erectile dysfunction for cardiovascular disease in younger men and those with diabetes.

Multiple published studies have established erectile dysfunction (ED) as an independent risk marker for cardiovascular disease (CVD). In fact, incident ED has a similar or greater predictive value for cardiovascular events than traditional risk factors including smoking, hyperlipidemia, and family history of myocardial infarction. Here, we review evidence that supports ED as a particularly significant harbinger of CVD in 2 populations: men <60 years of age and those with diabetes. Although addition of ED to the Framingham Risk Score only modestly improved the 10-year predictive capacity of the Framingham Risk Score for myocardial infarction or coronary death data in men enrolled in the Massachusetts Male Aging Study, other epidemiologic studies suggest that the predictive value of ED is quite strong in younger men. Indeed, in the Olmstead County Study, men 40 to 49 years of age with ED had a 50-fold higher incidence of new-incident coronary artery disease than those without ED. However, ED had less predictive value (5-fold increased risk) for coronary artery disease in men 70 years and older. Several studies, including a large analysis of more than 6300 men enrolled in the ADVANCE study, suggest that ED is a particularly powerful predictor of CVD in diabetic men as well. Based on the literature reviewed here, we encourage physicians to inquire about ED symptoms in all men more than 30 years of age with cardiovascular risk factors. Identification of ED, particularly in men <60 years old and those with diabetes, represents an important first step toward CVD risk detection and reduction.

Statin use and decreased risk of benign prostatic enlargement and lower urinary tract symptoms.

OBJECTIVE: To determine whether statin use is associated with a decreased risk of developing benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS). SUBJECTS AND METHODS: We conducted a retrospective, population-based cohort study of 2447 men, 40-79 years of age, residing in Olmsted County, MN, USA, in 1990, and followed these men biennially through 2007. Cox proportional hazard models were used to assess associations between statin use and new onset of moderate/severe LUTS (American Urological Association Symptom Index score >7), a decreased maximum urinary flow rate (<12 mL/s) or BPE (prostate volume >30 mL). RESULTS: Statin use was inversely associated with new onset of LUTS (Hazard ratio (HR) 0.39; 95% confidence interval (CI) 0.31-0.49), a decreased maximum flow rate (HR 0.53; 95% CI 0.34-0.82) and BPE (HR 0.40; 95% CI 0.23-0.69) after adjustment for baseline age and body mass index, diabetes, hypertension, coronary heart disease, smoking, alcohol use, activity level and non-steroidal anti-inflammatory use. The longest duration of statin use was associated with the lowest risk of developing each outcome (all tests for trend: P < 0.001). CONCLUSION: In this study, statin use was associated with a 6.5- to 7-year delay in the new onset of moderate/severe LUTS or BPE. While men typically take statin medications to prevent coronary heart disease events and related outcomes, these data suggest that men who use statins may also receive urologic benefits.

The association between statin use and the diagnosis of prostate cancer in a population based cohort.

PURPOSE: The effect of statin medication use on the risk of prostate cancer is unknown. MATERIALS AND METHODS: We examined data from a longitudinal, population based cohort of 2,447 men between 40 and 79 years old who were followed from 1990 to 2007. Information on statin use was self-reported and obtained by biennial questionnaires. A randomly selected subset of men (634, 26%) completed biennial urological examinations that included serum prostate specific antigen measurements. Information on prostate biopsy and prostate cancer was obtained through review of community medical records. RESULTS: Of 634 statin users 38 (6%) were diagnosed with prostate cancer vs 186 (10%) of 1,813 nonstatin users. Statin use was associated with a decreased risk of undergoing prostate biopsy (HR 0.31; 95% CI 0.24, 0.40), receiving a prostate cancer diagnosis (HR 0.36; 95% CI 0.25, 0.53) and receiving a high grade (Gleason 7 or greater) prostate cancer diagnosis (HR 0.25; 95% CI 0.11, 0.58). Statin use was also associated with a nonsignificantly decreased risk of exceeding a prostate specific antigen threshold of 4.0 ng/ml (HR 0.63; 95% CI 0.35, 1.13). In addition, a longer duration of statin use was associated with a lower risk of these outcomes (all tests for trend p <0.05). CONCLUSIONS: Statin use is associated with a decreased risk of prostate cancer diagnosis. This association may be explained by decreased detection or cancer prevention.

Surgical and minimally invasive treatments for Peyronie's disease.

PURPOSE OF REVIEW: Peyronie's disease is a relatively common condition affecting men with estimates of current prevalent rates ranging from 1 to 4%. However, it has no clear management protocols, primarily due to a lack of high quality evidence in support of treatment options. This article aims to review the recent published literature on management strategies for Peyronie's disease. RECENT FINDINGS: Intralesional interferon therapy has shown to result in significant improvement in Peyronie's disease plaques and curvature. Intralesional verapamil and extracorporeal shock wave therapy may help retard the progression of disease. Acellular, extracellular matrix-based grafts provide durable long-term satisfactory results in men requiring complex reconstruction. SUMMARY: Further clinical trails are warranted to evaluate the role of oral systemic therapies for early Peyronie's disease. Injection therapy, primarily with interferon, seems to be the most promising treatment for early stage Peyronie's disease. For men with established plaques, surgery using either plication or grafts forms the mainstay. There is an increasing trend to use autologous graft material that is commercially available and avoids donor site complications from autologous tissue.

Associations between C-reactive protein and benign prostatic hyperplasia/lower urinary tract symptom outcomes in a population-based cohort.

Inflammation may play a role in the development of benign prostatic hyperplasia and/or lower urinary tract symptoms (LUTS). Higher levels of C-reactive protein (CRP) may therefore be associated with the development of these outcomes. The authors examined the association of CRP levels measured in 1996 with rapid increases in prostate volume, prostate-specific antigen levels, and LUTS as well as rapid decreases in peak flow rates (through 2005) in a population-based cohort of men residing in Olmsted County, Minnesota. Men with CRP levels of > or =3.0 mg/L were more likely to have rapid increases in irritative LUTS (odds ratio (OR) = 2.14, 95% confidence interval (CI): 1.18, 3.85) and rapid decreases in peak flow rates (OR = 2.54, 95% CI: 1.09, 5.92) compared with men with CRP levels of <3.0 mg/L. CRP levels were not significantly associated with rapid increases in prostate volume, obstructive LUTS, or prostate-specific antigen levels. Associations were attenuated after adjusting for age, body mass index, hypertension, and smoking history (irritative LUTS: OR = 2.00, 95% CI: 1.04, 3.82; peak flow rate: OR = 2.45, 95% CI: 0.73, 8.25). These results suggest that rapid increases in irritative LUTS and rapid decreases in peak flow rates may be due to inflammatory processes.

Presumed circle area ratio of the prostate in a community-based group of men.

OBJECTIVE To determine the normal values for the presumed circle area ratio (PCAR) in a group of community-based men, and to determine whether PCAR is associated with specific urological outcomes. PATIENTS AND METHODS The study was a cross-sectional analysis among 328 Caucasian men (94% participation) residing in Olmsted County, Minnesota, USA. The PCAR was measured during prostatic ultrasonography. Lower urinary tract symptoms (LUTS) were measured using the American Urologic Association Symptom Index. The peak urinary flow rate was measured by a uroflowmeter, and the postvoid residual volume (PVR) was assessed using the BladderScan(TM) BVM 6500 (Verathon, Bothell, WA, USA). Correlations between PCAR and presence of LUTS, peak urinary flow rate, and PVR were determined using Spearman correlation coefficients. Unadjusted and adjusted odds ratios (ORs) were calculated using logistic regression to determine the associations between PCAR thresholds and categorical urological outcomes. RESULTS The median (interquartile range) PCAR was 0.85 (0.81-0.88). After adjusting for age and total prostate volume, men who had PCARs of >0.90 were more likely to have elevated overall and obstructive symptom scores (OR 2.95, 95% confidence interval 1.39-6.25, and 3.47, 1.63-7.39, respectively). CONCLUSION PCAR might add further information beyond total prostate volume when predicting the development of obstructive LUTS.

Smoking and acute urinary retention: the Olmsted County study of urinary symptoms and health status among men.

BACKGROUND: Previous reports have suggested an inverse relationship between smoking and surgery for benign prostatic hyperplasia (BPH). We hypothesized that acute urinary retention (AUR), an adverse outcome of this disease and indication for surgical treatment, may be related to smoking. METHODS: Study subjects were randomly selected from Olmsted County men aged 40-79 identified through the Rochester Epidemiology Project. Of the 3,854 eligible men, 2,089 (54%) completed a questionnaire that included the American Urological Association Symptom Score and assessed smoking status. Community medical records were examined for occurrence of AUR with documented catheterization in the subsequent 10 years and occurrence of BPH surgery. Proportional hazard models were used to assess the relationship between baseline smoking status and subsequent retention. RESULTS: In the 18,307 person-years of follow-up, 114 men had AUR. When compared to 727 never-smokers, there was a trend among the 336 current smokers to be at lower risk (Relative risk (RR) = 0.62, 95% Confidence Interval (CI) = 0.33, 1.18) whereas the 1,026 former smokers were at similar risk to non-smokers (RR = 1.0, 95%CI = 0.67, 1.46). Among men with moderate-severe symptoms at baseline, current smokers were at lower risk of retention compared to non-smokers (RR = 0.65, 95%CI = 0.22, 1.91) but the association approached the null among those with none-mild symptoms (RR = 0.91, 95% CI = 0.40, 2.06). CONCLUSIONS: Community-dwelling men who currently smoke may be at a modestly reduced risk of AUR. The magnitude of this association is sufficiently small that it seems unlikely that this explains a sizable proportion of the inverse association between smoking and surgically treated BPH.

Benign and malignant epididymal masses evaluated with scrotal sonography: clinical and pathologic review of 85 patients.

OBJECTIVE: The purpose of this study was to determine whether the clinical history and sonographic appearance of solid epididymal masses could aid in distinguishing benign and malignant disease. METHODS: We retrospectively reviewed the medical records of all patients who had solid epididymal masses evaluated by scrotal sonography at our institution between 1996 and 2004. We evaluated multiple clinical and sonographic variables, including lesion size, location, echogenicity, color Doppler characteristics, and calcifications. RESULTS: Of the 85 patients included in the study, 25 (29%) underwent surgical intervention, and 5 (6%) had malignant disease. A mass size of greater than 1.5 cm and the presence of color Doppler flow were statistically significant markers for malignancy (P < .05). Combining these 2 variables as a test for malignancy yielded sensitivity of 100%, specificity of 80%, a positive predictive value of 24%, and a negative predictive value of 100%. CONCLUSIONS: Most solid epididymal masses (94%) are benign. A size of greater than 1.5 cm and the presence of color Doppler flow may help identify possible malignant masses.

The associations between serum sex hormones, erectile function, and sex drive: the Olmsted County Study of Urinary Symptoms and Health Status among Men.

INTRODUCTION: Testosterone replacement therapy has been used in the treatment of sexual dysfunction; however, its use remains controversial, and the effectiveness and long-term health implications are unknown. AIM: To evaluate the association between sex hormone serum levels, erectile function, and sexual drive in a population-based sample of men. METHODS: A stratified random sample of men residing in Olmsted County, Minnesota, completed a questionnaire containing questions from the Brief Male Sexual Function Inventory (BMSFI), and participated in a clinical exam, which included serum hormone measurements. MAIN OUTCOME MEASURES: Levels of sexual drive (libido) and erectile function as assessed by the BMSFI and serum testosterone, bioavailable testosterone, and estradiol measurements. RESULTS: Out of 414 men, 294 had a regular sexual partner and androgen measurements at the 14th year of follow-up. Total testosterone and erectile function were significantly correlated even after adjustment for age (r = 0.12, P = 0.04). Conversely, total testosterone was not significantly correlated with sex drive (r = 0.08, P = 0.17). Bioavailable testosterone was significantly correlated with both erectile function and sex drive (r = 0.16, P = 0.01 and r = 0.20, P = 0.001, respectively). However, these associations disappeared after age adjustment (r = 0.04 and r = 0.09). CONCLUSIONS: These cross-sectional results suggest the relationship between sex hormones and sexual function is complex, and that the age-related decline in sexual function may be due to age-related declines in levels of bioavailable testosterone rather than total testosterone levels.

Pharmacoangiographic evidence of the presence and anatomical dominance of accessory pudendal artery(s).

PURPOSE: Potency preservation is one of the principal concerns surrounding newer developments in the management of organ confined carcinoma prostate. Nerve sparing techniques may not solely preserve erectile function and it is known that vascular factors may be an etiology of the dysfunction. The role of accessory pudendal arteries in the etiology and prevention of erectile dysfunction after radical prostatectomy is at present unclear. We reviewed pudendal angiograms in patients with erectile dysfunction to evaluate the prevalence and importance of these vessels. MATERIALS AND METHODS: Selective pudendal pharmacoangiograms were obtained in 79 consecutive patients with a history of erectile dysfunction. The aim was to identify accessory pudendal arteries, their origin and their significance relative to all identifiable pudendal arteries and the dorsal penile artery with respect to penile arterial inflow. RESULTS: An accessory pudendal artery was identified in 28 (35%) of the patients. The most common origin was the obturator artery. In 15 of the 28 men (54%) in whom an accessory artery was identified it appeared angiographically to be the dominant penile artery. In 3 patients it was apparently the only major arterial inflow to the penis. CONCLUSIONS: Accessory pudendal arteries may be identifiable with pharmacoangiograms in approximately a third of all men. Because they may be the dominant source of blood supply to the penis in some cases, their preservation during radical prostatectomy could be critical to erectile function following radical prostatectomy.

Dual implantation of penile and sphincter implants in the post-prostatectomy patient.

Despite major improvement in surgical techniques for radical pelvic surgery, including radical prostatectomy, major quality-of-life issues persist, such as postoperative erectile dysfunction and urinary incontinence. These two conditions have many common etiologies and often occur in the same patient. Patients with either of these conditions fail initial conservative or minimally invasive therapy and become candidates for prosthetic implants, such as artificial urinary sphincter and penile prosthesis. In the past three decades, there have been significant improvements in the mechanical properties of these devices, their functional capabilities, and surgical implantation techniques. Studies once suggested that implantation of both devices in one patient could lead to failure, but recent literature proves that patients benefit from simultaneous dual implantation. Specific benefits relate to shorter surgery time, with potentially lower infection rates. In this manuscript, we review the indications, techniques, merits, and safety of simultaneous dual implantation of the artificial urinary sphincter and penile prosthesis in the post-radical prostatectomy patient.