SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Physician Use of Sacral Neuromodulation among Medicare Beneficiaries with Overactive Bladder and Urinary Retention A. M. Suskind, J. Q. Clemens, Y. Zhang and B. K. Hollenbeck Department of Urology, University of California, San Francisco, California, and Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan Urology 2015; 86: 30e34. doi: 10.1016/j.urology.2015.04.003
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26026856 Editorial Comment: Use of sacral neuromodulation to treat patients with refractory overactive bladder has increased exponentially during the last 15 years. That being said, it is still unclear which patients are most likely to benefit from this therapy as opposed to alternative treatments. Therefore, providers often perform sacral neuromodulation test procedures before implantation of a permanent device. This provocative study documents that testing rates in the Medicare data set increased fourfold from 2005 to 2010 without a concomitant increase in implantation of a permanent device. On the one hand, this is good news. Providers are testing patients and are not inappropriately implanting a permanent device that would be of limited value. On the other hand, this fourfold increase in testing represents a significant added cost that, in the end, does not provide any symptom relief for patients suffering from overactive bladder or chronic urinary retention. Effectively this practice significantly detracts from the overall value of sacral neuromodulation. My concern is that payers and policy makers will ultimately look at the total cost of the therapy and decide that they will not cover this treatment. Urologists must start to identify which patients are most likely to benefit from sacral neuromodulation based on presenting symptoms and restrict testing to these patients. I recognize that we do not have a good understanding of this issue at this time, and to this end it needs to be a major focus of research going forward. Importantly we cannot rely on our colleagues in urogynecology or the device manufacturers to do this work. We must take the lead in documenting the value of this increasingly used therapy. David F. Penson, MD, MPH
Benign Prostatic Hyperplasia Re: The Role of Inflammation in Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Hyperplasia (BPH) and its Potential Impact on Medical Therapy V. Ficarra, M. Rossanese, M. Zazzara, G. Giannarini, M. Abbinante, R. Bartoletti, V. Mirone and F. Scaglione Department of Experimental and Clinical Medical Sciences, Urology Unit, University of Udine, Academic Medical Centre Hospital Udine, Udine, Italy Curr Urol Rep 2014; 15: 463. doi: 10.1007/s11934-014-0463-9
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25312251 Editorial Comment: Inflammation has been one of the buzzwords around multiple medical conditions, including cardiovascular disease, diabetes, Alzheimer disease and multiple sclerosis. There has been an emerging body of literature suggesting that inflammation has a role in benign prostatic
689
BENIGN PROSTATIC HYPERPLASIA
690
hyperplasia as well. It has been reported that infiltrating inflammatory cells may be the putative link between various hormonal changes and growth patterns in the prostate. The cycle of hormonal changes and inflammation initiates and maintains a chronic process of remodeling and untimely enlargement. These processes act with T and B lymphocytes and macrophages to stimulate cytokine release and a cascade of growth factors. How does this activity manifest? Previously the presence of inflammation on either a prostate biopsy or transurethral prostatectomy specimen was written off as clinically insignificant. It is reasonable that inflammation is the driving force behind prostate specific antigen increases, and in surgical specimen enlargement and consequent lower urinary tract symptoms. We also know that prostate calcifications are much more common in symptomatic men. It is plausible that these findings are related to secondary manifestations of an underlying inflammatory process. So how do these findings impact our therapeutic strategies? Data on 5alpha-reductase inhibitors suggest that prostate volume reduction may be related to altering the arc of inflammation within the prostate. Do these agents act as anti-inflammatory mediators within the prostate and change the balance between growth and apoptosis? Alpha blockers do not seem to alter inflammation. Ironically more classic anti-inflammatory agents do not seem to significantly alter either prostate size or growth. Clearly affecting the hormonal milieu allows these processes to occur. The bottom line is that large prostates tend to have a greater degree of inflammation, and agents such as 5alpha-reductase inhibitors may be the most useful for therapy. Steven A. Kaplan, MD
Suggested Reading Delongchamps NB, de la Roza G, Chandan V et al: Evaluation of prostatitis in autopsied prostatesdis chronic inflammation more associated with benign prostatic hyperplasia or cancer? J Urol 2008; 179: 1736.
Re: Improvement of Lower Urinary Tract Symptoms and Sexual Activity after Open Simple Prostatectomy: Prospective Analysis of 50 Cases L. Montesi, L. Quaresima, M. Tiroli, V. Lacetera, U. Cantoro, G. Sbrollini, G. Muzzonigro and M. Polito Institute of Urology, AOU United Hospitals, Marche Polytechnic University, Ancona, Italy Arch Ital Urol Androl 2014; 86: 353e355. doi: 10.4081/aiua.2014.4.353
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25641470 Editorial Comment: What is the definition of a large prostate? There appears to be a myriad of responses based on geography, surgical experience and technique. For example the European Association of Urology guidelines suggest that large benign prostatic hyperplasia is defined as volume greater than 80 to 100 ml. Open prostatectomy would be a favored approach. In our hands these procedures are always done transurethrally. In the hands of experts in holmium/thulium/ GreenLightÔ laser resection these operations would be done similarly via a transurethral route. That said, most urologists around the world would be more likely to perform open prostatectomy in these men. The data here confirm that the procedure is safe and effective. What is interesting is that erectile function in some men also improved. Although not reported, one would assume that ejaculatory function was diminished. It would have been interesting to know what the total sexual satisfaction was postoperatively. We are aware of the association between lower urinary tract symptoms and sexual function. Much of the literature focuses on potential decreases in erectile and ejaculatory function and/or sexual satisfaction. There have been other reports that sexual function may be improved as well, particularly in younger men. The data reported seem to confirm that in some men, especially those who are younger or more sexually active, improvement in voiding parallels improvement in erectile function. Ultimately each of us develops our own algorithm of the types of techniques we favor and our own threshold for performing open prostatectomy. Steven A. Kaplan, MD
BENIGN PROSTATIC HYPERPLASIA
691
Suggested Reading Tubaro A, Carter S, Hind A et al: A prospective study of the safety and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. J Urol 2001; 166: 172.
Re: Impact of 120-W 2-mm Continuous Wave Laser Vapoenucleation of the Prostate on Sexual Function € and X. Li Y. Wang, J. Shao, Y. Lu, Y. Lu Department of Urology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China Lasers Med Sci 2014; 29: 689e693. doi: 10.1007/s10103-013-1386-2
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23828495 Editorial Comment: One would expect that following transurethral resection/vaporization or enucleation of the prostate erectile function might be negatively affected. It is noteworthy that there are some reports that it might be improved. Ejaculatory function is variable based on technique and amount of tissue removed. Overall sexual satisfaction is highly dependent on whether and to what degree these parameters are affected. In this study the authors retrospectively analyzed men who underwent treatment with a 120 watt, 2 mm continuous wave laser or standard transurethral resection of the prostate. The bottom line is that erectile function showed a marginal although insignificant improvement in both groups, ejaculation was negatively impacted and overall sexual satisfaction was unchanged. However, the orgasm domain was diminished at 12 months. These data are what one would expect from procedures that remove a significant amount of adenoma. Is there an inherent benefit of a particular technique over another regarding ejaculatory function? It is doubtful. One would suspect that if a procedure results in less adenoma being removed, ejaculation might be more likely to be preserved. Exceptions to this concept are in those men with significant middle lobe hypertrophy. Removal of the middle lobe alone tends to result in significant improvement in lower urinary tract symptoms with preservation of ejaculation. While marketing claims abound that sexual function is improved after some transurethral surgical procedures, be wary. Our own experiences suggest that postoperative sexual function in well conducted procedures is typically similar Steven A. Kaplan, MD
Suggested Reading Briganti A, Naspro R, Gallina A et al: Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. J Urol 2006; 175: 1817.
Re: The Impact of Abdominal Aortic Calcification and Visceral Fat Obesity on Lower Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia T. Motoya, S. Matsumoto, S. Yamaguchi, N. Wada, A. Numata, H. Osanai and H. Kakizaki Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan Int Urol Nephrol 2014; 46: 1877e1881. doi: 10.1007/s11255-014-0757-3
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24908284 Editorial Comment: The obesity epidemic affects virtually every aspect of health care. For example in a recent report the rate of total knee replacements almost doubled between 2000 and 2010 for Americans older than 45 years, while the average age of patients decreased by more than 2 years, to
BENIGN PROSTATIC HYPERPLASIA
692
66.2. Two big demographic shifts help explain the knee replacement boom and, one could argue, the incidence of voiding and sexual dysfunction in men and women. People are living longer, with life expectancy for a 65-year-old increased by a year and a half between 2000 and 2010 in the United States. More importantly there has been a marked increase in the overweight and obese. This study examines proxies of metabolic dysfunction that may herald urological conditions. The authors report that an aortic calcification index was associated with voided volume, and less so with maximum urinary flow rate, but had little correlation with subjective symptoms. In contrast, visceral fat area was significantly correlated with urinary frequency and nocturia. Much of this information makes sense. Visceral fat area has previously been noted to be among the strongest predictors of overactive bladder type symptoms, which may be partly due to autonomic sympathetic overactivity. Issues of sleep apnea (Pickwickian syndrome) may also have a role. Atherosclerotic changes may herald alterations in blood flow to the bladder, which may result in changes in bladder wall function, capacity and voided volume. Clearly metabolic syndrome and obesity have deleterious consequences, and urinary function is not spared. Proxies that are commonly used in cardiovascular and diabetic diseases may be useful in helping us to predict and more accurately diagnose cases of underlying urological dysfunction. Steven A. Kaplan, MD
Suggested Reading Kaplan SA: Male pelvic health: a urological call to arms. J Urol 2006; 176: 2351. Parsons JK, Sarma AV, McVary K et al: Obesity and benign prostatic hyperplasia: clinical connections, emerging etiological paradigms and future directions. J Urol, suppl., 2009; 182: S27.
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Physician Use of Sacral Neuromodulation among Medicare Beneficiaries with Overactive Bladder and Urinary Retention A. M. Suskind, J. Q. Clemens, Y. Zhang and B. K. Hollenbeck Department of Urology, University of California, San Francisco, California, and Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan Urology 2015; 86: 30e34. doi: 10.1016/j.urology.2015.04.003
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26026856 Editorial Comment: Use of sacral neuromodulation to treat patients with refractory overactive bladder has increased exponentially during the last 15 years. That being said, it is still unclear which patients are most likely to benefit from this therapy as opposed to alternative treatments. Therefore, providers often perform sacral neuromodulation test procedures before implantation of a permanent device. This provocative study documents that testing rates in the Medicare data set increased fourfold from 2005 to 2010 without a concomitant increase in implantation of a permanent device. On the one hand, this is good news. Providers are testing patients and are not inappropriately implanting a permanent device that would be of limited value. On the other hand, this fourfold increase in testing represents a significant added cost that, in the end, does not provide any symptom relief for patients suffering from overactive bladder or chronic urinary retention. Effectively this practice significantly detracts from the overall value of sacral neuromodulation. My concern is that payers and policy makers will ultimately look at the total cost of the therapy and decide that they will not cover this treatment. Urologists must start to identify which patients are most likely to benefit from sacral neuromodulation based on presenting symptoms and restrict testing to these patients. I recognize that we do not have a good understanding of this issue at this time, and to this end it needs to be a major focus of research going forward. Importantly we cannot rely on our colleagues in urogynecology or the device manufacturers to do this work. We must take the lead in documenting the value of this increasingly used therapy. David F. Penson, MD, MPH
Benign Prostatic Hyperplasia Re: The Role of Inflammation in Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Hyperplasia (BPH) and its Potential Impact on Medical Therapy V. Ficarra, M. Rossanese, M. Zazzara, G. Giannarini, M. Abbinante, R. Bartoletti, V. Mirone and F. Scaglione Department of Experimental and Clinical Medical Sciences, Urology Unit, University of Udine, Academic Medical Centre Hospital Udine, Udine, Italy Curr Urol Rep 2014; 15: 463. doi: 10.1007/s11934-014-0463-9
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25312251 Editorial Comment: Inflammation has been one of the buzzwords around multiple medical conditions, including cardiovascular disease, diabetes, Alzheimer disease and multiple sclerosis. There has been an emerging body of literature suggesting that inflammation has a role in benign prostatic
689
BENIGN PROSTATIC HYPERPLASIA
690
hyperplasia as well. It has been reported that infiltrating inflammatory cells may be the putative link between various hormonal changes and growth patterns in the prostate. The cycle of hormonal changes and inflammation initiates and maintains a chronic process of remodeling and untimely enlargement. These processes act with T and B lymphocytes and macrophages to stimulate cytokine release and a cascade of growth factors. How does this activity manifest? Previously the presence of inflammation on either a prostate biopsy or transurethral prostatectomy specimen was written off as clinically insignificant. It is reasonable that inflammation is the driving force behind prostate specific antigen increases, and in surgical specimen enlargement and consequent lower urinary tract symptoms. We also know that prostate calcifications are much more common in symptomatic men. It is plausible that these findings are related to secondary manifestations of an underlying inflammatory process. So how do these findings impact our therapeutic strategies? Data on 5alpha-reductase inhibitors suggest that prostate volume reduction may be related to altering the arc of inflammation within the prostate. Do these agents act as anti-inflammatory mediators within the prostate and change the balance between growth and apoptosis? Alpha blockers do not seem to alter inflammation. Ironically more classic anti-inflammatory agents do not seem to significantly alter either prostate size or growth. Clearly affecting the hormonal milieu allows these processes to occur. The bottom line is that large prostates tend to have a greater degree of inflammation, and agents such as 5alpha-reductase inhibitors may be the most useful for therapy. Steven A. Kaplan, MD
Suggested Reading Delongchamps NB, de la Roza G, Chandan V et al: Evaluation of prostatitis in autopsied prostatesdis chronic inflammation more associated with benign prostatic hyperplasia or cancer? J Urol 2008; 179: 1736.
Re: Improvement of Lower Urinary Tract Symptoms and Sexual Activity after Open Simple Prostatectomy: Prospective Analysis of 50 Cases L. Montesi, L. Quaresima, M. Tiroli, V. Lacetera, U. Cantoro, G. Sbrollini, G. Muzzonigro and M. Polito Institute of Urology, AOU United Hospitals, Marche Polytechnic University, Ancona, Italy Arch Ital Urol Androl 2014; 86: 353e355. doi: 10.4081/aiua.2014.4.353
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25641470 Editorial Comment: What is the definition of a large prostate? There appears to be a myriad of responses based on geography, surgical experience and technique. For example the European Association of Urology guidelines suggest that large benign prostatic hyperplasia is defined as volume greater than 80 to 100 ml. Open prostatectomy would be a favored approach. In our hands these procedures are always done transurethrally. In the hands of experts in holmium/thulium/ GreenLightÔ laser resection these operations would be done similarly via a transurethral route. That said, most urologists around the world would be more likely to perform open prostatectomy in these men. The data here confirm that the procedure is safe and effective. What is interesting is that erectile function in some men also improved. Although not reported, one would assume that ejaculatory function was diminished. It would have been interesting to know what the total sexual satisfaction was postoperatively. We are aware of the association between lower urinary tract symptoms and sexual function. Much of the literature focuses on potential decreases in erectile and ejaculatory function and/or sexual satisfaction. There have been other reports that sexual function may be improved as well, particularly in younger men. The data reported seem to confirm that in some men, especially those who are younger or more sexually active, improvement in voiding parallels improvement in erectile function. Ultimately each of us develops our own algorithm of the types of techniques we favor and our own threshold for performing open prostatectomy. Steven A. Kaplan, MD
BENIGN PROSTATIC HYPERPLASIA
691
Suggested Reading Tubaro A, Carter S, Hind A et al: A prospective study of the safety and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. J Urol 2001; 166: 172.
Re: Impact of 120-W 2-mm Continuous Wave Laser Vapoenucleation of the Prostate on Sexual Function € and X. Li Y. Wang, J. Shao, Y. Lu, Y. Lu Department of Urology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China Lasers Med Sci 2014; 29: 689e693. doi: 10.1007/s10103-013-1386-2
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23828495 Editorial Comment: One would expect that following transurethral resection/vaporization or enucleation of the prostate erectile function might be negatively affected. It is noteworthy that there are some reports that it might be improved. Ejaculatory function is variable based on technique and amount of tissue removed. Overall sexual satisfaction is highly dependent on whether and to what degree these parameters are affected. In this study the authors retrospectively analyzed men who underwent treatment with a 120 watt, 2 mm continuous wave laser or standard transurethral resection of the prostate. The bottom line is that erectile function showed a marginal although insignificant improvement in both groups, ejaculation was negatively impacted and overall sexual satisfaction was unchanged. However, the orgasm domain was diminished at 12 months. These data are what one would expect from procedures that remove a significant amount of adenoma. Is there an inherent benefit of a particular technique over another regarding ejaculatory function? It is doubtful. One would suspect that if a procedure results in less adenoma being removed, ejaculation might be more likely to be preserved. Exceptions to this concept are in those men with significant middle lobe hypertrophy. Removal of the middle lobe alone tends to result in significant improvement in lower urinary tract symptoms with preservation of ejaculation. While marketing claims abound that sexual function is improved after some transurethral surgical procedures, be wary. Our own experiences suggest that postoperative sexual function in well conducted procedures is typically similar Steven A. Kaplan, MD
Suggested Reading Briganti A, Naspro R, Gallina A et al: Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. J Urol 2006; 175: 1817.
Re: The Impact of Abdominal Aortic Calcification and Visceral Fat Obesity on Lower Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia T. Motoya, S. Matsumoto, S. Yamaguchi, N. Wada, A. Numata, H. Osanai and H. Kakizaki Department of Renal and Urologic Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan Int Urol Nephrol 2014; 46: 1877e1881. doi: 10.1007/s11255-014-0757-3
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24908284 Editorial Comment: The obesity epidemic affects virtually every aspect of health care. For example in a recent report the rate of total knee replacements almost doubled between 2000 and 2010 for Americans older than 45 years, while the average age of patients decreased by more than 2 years, to
BENIGN PROSTATIC HYPERPLASIA
692
66.2. Two big demographic shifts help explain the knee replacement boom and, one could argue, the incidence of voiding and sexual dysfunction in men and women. People are living longer, with life expectancy for a 65-year-old increased by a year and a half between 2000 and 2010 in the United States. More importantly there has been a marked increase in the overweight and obese. This study examines proxies of metabolic dysfunction that may herald urological conditions. The authors report that an aortic calcification index was associated with voided volume, and less so with maximum urinary flow rate, but had little correlation with subjective symptoms. In contrast, visceral fat area was significantly correlated with urinary frequency and nocturia. Much of this information makes sense. Visceral fat area has previously been noted to be among the strongest predictors of overactive bladder type symptoms, which may be partly due to autonomic sympathetic overactivity. Issues of sleep apnea (Pickwickian syndrome) may also have a role. Atherosclerotic changes may herald alterations in blood flow to the bladder, which may result in changes in bladder wall function, capacity and voided volume. Clearly metabolic syndrome and obesity have deleterious consequences, and urinary function is not spared. Proxies that are commonly used in cardiovascular and diabetic diseases may be useful in helping us to predict and more accurately diagnose cases of underlying urological dysfunction. Steven A. Kaplan, MD
Suggested Reading Kaplan SA: Male pelvic health: a urological call to arms. J Urol 2006; 176: 2351. Parsons JK, Sarma AV, McVary K et al: Obesity and benign prostatic hyperplasia: clinical connections, emerging etiological paradigms and future directions. J Urol, suppl., 2009; 182: S27.
