Overactive Bladder

Reviewing the Literature

RIU0288_11-20.qxd 11/20/06 2:50 PM Page 234 Prostate Cancer continued Warlick and colleagues from Johns Hopkins wanted to answer a slightly different question than the previous group. An active expectant management approach is rarely used in men diagnosed with prostate cancer, so as not to lose the window of opportunity for early cure. Rather than compare survival among patients who had been treated versus those who had been observed, they wished to determine whether there was a difference in pathologic outcomes among men undergoing radical prostatectomy in an expectant management protocol as compared with those undergoing immediate surgery. Between January 1, 1995 and February 1, 2005, 320 men had been enrolled in the expectant management program at Johns Hopkins. This program is offered to any man who has had a new diagnosis of prostate cancer made by a 12 core needle biopsy that demonstrates cancer with Gleason score 6 or less involving fewer than 3 cores and less than 50% of any individual core. At entry these men must have had PSA density (PSAD) less than 0.15 ng/mL/g. Thirtyeight patients from the expectant management program (median age, 61 years) who had ultimately undergone radical prostatectomy were compared with 150 men (median age, 61 years) matched for age and PSA level who had undergone immediate surgery. Delayed surgical intervention took place at a median of 26.5 months (95% CI, 17-32 months; range, 12-73 months) after diagnosis, whereas the immediate surgery group underwent surgical intervention at a median of 3 months (95% CI, 2-4 months; range, 1-9 months) after diagnosis. “Noncurable cancer” was defined as pathology associated with a less than 75% chance of remaining free of prostate cancer at 10 years after surgery. Noncurable cancer was diagnosed in 9 (23%) of the 38 patients from the expectant management group and in 24 (16%) of the 150 men in the immediate intervention group. After adjustment for age and PSAD in a Mantel-Haenszel analysis, the risks of noncurable cancer associated with delayed and immediate intervention were not statistically significantly different (relative risk  1.08; 95% CI, 0.55-2.12; P  .819, twosided Cochran-Mantel-Haenszel statistic). Age, PSA level, and PSA density were all statistically significantly associated with the risk of noncurable cancer (P  .030, .013, and .008, respectively). The researchers concluded that delayed prostate cancer surgery for patients with small, lower-grade prostate cancers followed expectantly does not seem to compromise the surgical curability of these cancers. Wong and colleagues come out for the immediate treatment of low-grade, clinically localized prostate cancer, whereas Warlick and colleagues advocate watchful waiting as a potential option for the same disease. One might justifiably wonder how these two groups could arrive at such 234 VOL. 8 NO. 4 2006 REVIEWS IN UROLOGY different conclusions. One could argue that the Johns Hopkins group does not assess the survival outcomes of these patients, and thus presents immature data that might in time demonstrate a survival advantage to immediate intervention. However, what is more likely is that the Johns Hopkins group presents the results of a study in which patients were carefully selected and followed according to a defined algorithm. Although expectant management is not a good management strategy for all prostate cancer, it clearly can be applied in the setting of low-grade and low-stage disease in patients who will be carefully followed. References 1. 2. 3. 4. 5. Epstein JI, Walsh PC, Carmichael M, Brendler CB. Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA. 1994;271:368-374. Bastian PJ, Mangold LA, Epstein JI, Partin AW. Characteristics of insignificant clinical T1c prostate tumors. A contemporary analysis. Cancer. 2004;101: 2001-2005. Humphrey PA, Keetch DW, Smith DS, et al. Prospective characterization of pathological features of prostatic carcinomas detected via serum prostate specific antigen based screening. J Urol. 1996;155:816-820. Allaf ME, Carter HB. Update on watchful waiting for prostate cancer. Curr Opin Urol. 2004;14:171-175. Epstein JI. Gleason score 2-4 adenocarcinoma of the prostate on needle biopsy: a diagnosis that should not be made. Am J Surg Pathol. 2000;24:477-478. Overactive Bladder Health Care Usage, Botulinum Toxin for Overactive Bladder Reviewed by Akira Furuta, MD, PhD, Michael B. Chancellor, MD Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA [Rev Urol. 2006;8(4):234-235] © 2006 MedReviews, LLC lthough overactive bladder (OAB) is ranked among the 10 most common chronic medical conditions in the United States, the level of OAB-associated medical treatment remains largely unknown. Investigators at the Florida International University School of Public Health asked a simple but relevant question: How many patients with OAB actually seek medical help? A RIU0288_11-20.qxd 11/20/06 2:50 PM Page 235 Fertility Medical Visits Among Adults With Symptoms Commonly Associated With an Overactive Bladder Kim SH, Boye M, Bhattacharyya SK, et al. BJU Int. 2006;97:551-554. To obtain estimates of the use of health care by adult patients with symptoms of OAB, Kim and associates examined three US databases (the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, and the National Hospital Discharge Survey) for the year 2000. During that year, adult Americans made 1.4 million ambulatory visits to non-federal, office-based physicians with International Classification of Disease (ICD-9) coding indicative of OAB symptoms. The prevalence of OAB is estimated to be 34 million adult Americans. When compared with this prevalence, the 1.4 million ambulatory visits reported by Kim and colleagues suggest that as few as 4% of adult Americans with OAB sought medical treatment during the year 2000. These results therefore suggest a large unmet medical need among adult Americans with OAB. However, most patients with OAB also have other medical issues, such as diabetes and hypertension. Could there be significant under-reporting of OAB codes due to doctors deciding to code other conditions for which patients are coming to their offices? At present there is no way to answer this, and the truth might be that both scenarios are correct. After botulinum toxin injection, the volume of the first involuntary detrusor contraction and bladder capacity increased twofold, whereas postvoid residual volume increased fourfold for both patient groups after 1 month, decreasing slightly at 3 months. Complete continence and improvement of incontinence grade, respectively, were achieved in 1 (8.3%) and 5 (41.7%) patients with CVA and in 4 (33.3%) and 7 (58.3%) patients with SCI. However, patients in both groups experienced an increase in voiding difficulty after treatment. The therapeutic effect declined gradually after 3 months, and all patients experienced symptom relapse by 6 months. Dr. Kuo concluded that suburothelial botulinum A toxin at a dose of 200 U increased bladder capacity and improved incontinence in more than 90% of SCI patients but only 50% of the patients with CVA. This is an interesting observation that has not yet been confirmed or refuted at another institution. It is hoped that the US Food and Drug Administration phase III neurogenic bladder botulinum toxin study that began in July 2006 will be able to address whether specific types of neurological conditions are associated with different outcomes from botulinum toxin injection. Fertility Reviewed by Jacob Rajfer, MD Therapeutic Effects of Suburothelial Injection of Botulinum A Toxin for Neurogenic Detrusor Overactivity Due to Chronic Cerebrovascular Accident and Spinal Cord Lesions Department of Urology, The David Geffen School of Medicine at UCLA, Los Angeles, and Division of Urology, Harbor-UCLA Medical Center, Torrance, CA [Rev Urol. 2006;8(4):235-236] © 2006 MedReviews, LLC Kuo HC. Urology. 2006;67:232-236. Carnitine and Male Infertility Dr. Kuo at the Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan, is an expert on the use of botulinum toxin in the bladder. In a study of 24 patients, he examined the effects of suburothelial injection of botulinum A toxin for neurogenic detrusor overactivity due to chronic cerebrovascular accident (CVA) (n  12) or spinal cord injury (SCI) (n  12). The patients, whose neurogenic detrusor overactivity was refractory to anticholinergics, were treated with 200 U of botulinum A toxin injected into the suburothelial space. The clinical effects on lower urinary tract symptoms and urodynamic parameters were assessed. ne of the difficult aspects of treating infertile men is that there are no recommended medical therapies for men with idiopathic oligospermia. This applies to the drug clomiphene citrate (CC). Although CC has at times been used empirically to treat men with idiopathic oligospermia, stringent, randomized, blinded, placebocontrolled trials demonstrating the efficacy of CC are lacking. As a result, physicians treating male infertility are always hopeful that some compound, which may have been associated with sperm function, will turn out to be the successful medication they have been searching for. One such compound that has captured the imagination is O VOL. 8 NO. 4 2006 REVIEWS IN UROLOGY 235