Fertility
Prostate Cancer continued degree by the adequacy rate, which is dependent on the amount of manipulation of the prostate (digital rectal examination) before urine collection. Additional technical refinement will further enhance the test’s sensitivity. Complexed Prostate-Specific Antigen (PSA) Reduces Unnecessary Prostate Biopsies in the 2.6-4.0 ng/mL Range of Total PSA Parsons JK, Brawer MK, Cheli CD, Partin AW, Djavan R. BJU Int. 2004;94:47-50. The complexed prostate-specific antigen (cPSA) assay, which measures the amount of PSA bound to serum proteins (primarily -1 antichymotrypsin), is emerging as an With a significantly higher positive predictive value for the uPM3 assay, unnecessary biopsies can be minimized and rebiopsy can be better planned. important test for prostate cancer detection. The rationale for cPSA testing is that the proportion of cPSA is greater in men with prostate cancer. Parsons and colleagues analyzed data from 2 multicenter trials, one from Europe and the other from the United States, to compare the performance of cPSA with tPSA and percentage-free PSA (f/t PSA) in the diagnosis of prostate cancer for the tPSA range 2.6-4.0 ng/mL. Of 316 men with tPSA levels in this range, 82 (26%) were diagnosed with prostate cancer on biopsy. Receiver operating curve analysis of all 316 men showed an area under curve (AUC) of 0.63, significantly greater than the AUC for tPSA of 0.56. At a sensitivity of 95%, threshold values of 2.3 ng/mL for cPSA and 2.73 ng/mL for tPSA provided specificities of 20.1% and 9.8%, respectively. Compared with f/t PSA, the AUC values of both tests were similar (0.63 vs 0.64). With these data from the largest analysis to date of the diagnostic performance of cPSA at a tPSA of 2.6-4.0 ng/mL, the authors conclude that cPSA is an excellent single test that provides improved specificity over tPSA and comparable specificity to f/t PSA for detecting prostate cancer, and may reduce the number of unnecessary prostate biopsies in the 2.6-4.0 ng/mL tPSA range. cPSA has shown potential to replace tPSA as a screening test for prostate cancer. However, further studies are required to determine the ageadjusted values (cutoffs) for screening. 64ºººVOL. 7 NO. 1ºº2005ººREVIEWS IN UROLOGY Fertility Effect of Testis Biopsy on Testosterone Production Reviewed by Jacob Rajfer, MD The David Geffen School of Medicine at UCLA and Division of Urology, Harbor-UCLA Medical Center, Los Angeles, CA [Rev Urol. 2005;7(1):64-65] © 2005 MedReviews, LLC ver since Tash and Schlegel1 published their observation that a testis biopsy for sperm extraction “shocks” the spermatogenic compartment such that it takes 6 months to recover normal spermatogenesis, very little attention has been paid to what happens to the interstitial compartment in this setting. Because testosterone is made in the interstitial compartment, it would be important to know whether such a shock occurs within this compartment and whether testosterone production is affected. Because testosterone in high local concentrations is necessary for normal spermatogenesis, a local drop in this level with a testis biopsy could be the reason spermatogenesis is delayed post testis biopsy and does not recover until testosterone production returns to normal. E Serum Testosterone Levels in Patients with Nonmosaic Klinefelter Syndrome After Testicular Sperm Extraction for Intracytoplasmic Sperm Injection Okada H, Shirakawa T, Ishikawa T, et al. Fertil Steril. 2004;82:237-238. To provide insight into this issue, Okada and colleagues measured the serum testosterone levels in patients with Klinefelter syndrome who were undergoing some form of testicular sperm extraction for in vitro fertilization. In this procedure, which is analogous to a testis biopsy, the authors found that serum testosterone levels were reduced between 25% and 40% (approximately) at 6 months and recovered very little at 12 months following the testis surgery. Similar results were observed for the patients who had a conventional testis biopsy for sperm extraction and those who underwent a microscopic microdissection, in which minimal testis tissue is excised.2 This finding suggests that the effects on the testis following such a biopsy may be more permanent Prostatitis than originally thought and that patients undergoing such a procedure need to be made aware of this possible sequela. Although it is true that many patients with Klinefelter syndrome are already hypogonadal, the further decrease in serum testosterone in these patients may necessitate the use of exogenous androgen replacement. One disclaimer from a study such as this is that it is unknown whether this observation would also be seen in non-Klinefelter patients, in whom the testicular mass would be much greater than that found in Klinefelter patients. In addition, although serum testosterone is a surrogate marker for intratesticular testosterone levels, it is still unknown whether a drop of between 25% and 40% on serum testosterone translates into a similar drop in intratesticular levels. References 1. 2. Tash J, Schlegel PN. Histologic effects of testicular sperm extraction on the testicle in men with nonobstructive azoospermia. Urology. 2001;57:334-337. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Hum Reprod. 1999;14:131-135. Prostatitis Antibiotics and -Blockers for Chronic Prostatitis: Evidence From Recent Randomized Placebo-Controlled Studies Reviewed by J. Curtis Nickel, MD, FRCSC small studies in the older urologic literature propagated this medical strategy for CP/CPPS. Ciprofloxacin or Tamsulosin in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Randomized, Double-Blind Trial Alexander RB, Propert KJ, Schaeffer AJ, et al. Ann Intern Med. 2004;141:581-589. Alexander and colleagues, from the National Institutes of Health (NIH) Chronic Prostatitis Collaborative Research Network, recently published a 6-week study that randomized 196 men with refractory, long-standing CP/CPPS to double-blind therapy with ciprofloxacin, tamsulosin, both drugs, or placebo in a 2 × 2 factorial design. The study employed validated outcome parameters including the NIHChronic Prostatitis Symptom Index (CPSI) and standardized patient global assessments. The NIH-CPSI total score decreased modestly in all the treatment groups, including placebo, but no statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin or tamsulosin versus no tamsulosin. The authors conclude that ciprofloxacin and tamsulosin do not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms. This is an important paper, particularly for the treatment of men with CP/CPPS of long duration who have undergone multiple previous therapies. However, can the results of this study be extrapolated to men with CP/CPPS who are recently diagnosed (or symptomatic) or who are treatment naïve to antibiotics and/or -blockers? Other recently published randomized, placebo-controlled trials may help shed some light on this dilemma. Department of Urology, Queen's University, Kingston, Ontario, Canada [Rev Urol. 2005;7(1):65-66] © 2005 MedReviews, LLC ntibiotics and -blockers are the 2 most common treatments employed by urologists for patients presenting with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), regardless of culture results and/or evidence of obstructive voiding. These medications are used because antibiotics are the primary therapy for the much rarer chronic bacterial prostatitis (associated with recurrent urinary tract infections and/or bacteriuria) and -blockers are the primary therapy for the lower urinary tract symptoms associated with benign prostatic hyperplasia (which may be very similar to those experienced by men with CP/CPPS). Anecdotal experience and A Levofloxacin for Chronic Prostatitis/Chronic Pelvic Pain Syndrome in Men: A Randomized, Placebo-Controlled Multi-Center Trial Nickel JC, Downy J, Clark J, et al. Urology. 2003;62:614-617. A randomized, placebo-controlled study comparing levofloxacin with placebo for 6 weeks in heavily pretreated men again showed no statistically or clinically significant difference between levofloxacin and placebo. There have been no treatment trials published comparing any antibiotic therapy with placebo in newly diagnosed, antibiotic-naïve men. It has been suggested that these important studies did not unequivocally show that antibiotics are not useful in all patients with chronic prostatitis, and further studies VOL. 7 NO. 1ºº2005ººREVIEWS IN UROLOGYºººº65