E. García-Cruz

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment

Study Type – Prognosis (case series)

Metabolic Syndrome in Men with Low Testosterone Levels: Relationship with Cardiovascular Risk Factors and Comorbidities and with Erectile Dysfunction

INTRODUCTION Testosterone deficiency and metabolic syndrome (MetS) are strongly associated. Patients consulting for sexual dysfunction may have testosterone deficiency, providing a valuable opportunity to assess MetS. The identification of variables predicting MetS is of great importance. AIMS To identify cardiovascular comorbidities and risk factors, including erectile dysfunction (ED), associated with MetS in men aged≥45 with total testosterone (TT)<8 nmol/L (or <12 nmol/L when calculated free testosterone was <50 pmol/L) and to gain further insight into the relationship between both conditions. METHODS Data were collected from a multicenter, cross-sectional, observational study conducted in Spain among men visiting mens health-care offices with a confirmed diagnosis of testosterone deficiency. Subjects with data for MetS assessment were included in this analysis. Other data available were anthropometrics, toxic habits, cardiovascular comorbidities, ED diagnosis, and TT values. MAIN OUTCOME MEASURES The MetS harmonized definition was used. Waist circumference threshold was 94 cm. ED was diagnosed and classified using the International Index of Erectile Function-5 (IIEF-5) questionnaire. Bivariate and multivariate logistic regression analyses were performed to calculate odds ratios (ORs) for MetS. RESULTS Mean age was 61.2±8.1 years. Prevalences of ED and MetS were 97.6% and 69%, respectively, both increasing with age. Bivariate analysis showed that moderate or severe ED, obesity, and peripheral vascular disease (PVD) were the variables associated with the greatest odds of MetS (OR=2.672 and 2.514, respectively), followed by alcohol intake (OR=1.911). Tobacco use, ag,e and testosterone deficiency severity had a minimal effect that disappeared on multivariate analysis. Elevated triglycerides and HDL-cholesterol were MetS risk factors associated with a lower TT level. CONCLUSION The high prevalence of MetS among men with testosterone deficiency highlights the opportunity to assess cardiovascular health in patients consulting for sexual dysfunction. Moderate to severe ED, obesity, PVD, and alcohol intake significantly increase the likelihood of MetS.

Second to fourth digit ratio, adult testosterone level and testosterone deficiency

Study Type – Diagnostic (exploratory cohort)

Higher sex hormone-binding globulin and lower bioavailable testosterone are related to prostate cancer detection on prostate biopsy.

Abstract Objective. Recent studies show an inverse relationship between testosterone levels and prostate cancer (PCa). The usefulness of hormonal patterns in PCa diagnosis is controversial. This study aimed to determine the relationship between hormonal patterns and PCa, and to find a cut-off point of hormone levels to assess PCa risk. Material and methods. A prospective analysis was undertaken of 279 patients referred for first or second prostate biopsy in the Hospital Clínic Barcelona from November 2006 to May 2009. The indication for prostate biopsy was suspicion of PCa based on the results of digital rectal examination (DRE) and/or elevation of serum prostate-specific antigen (PSA). Screening was carried out with a 5+5-core transrectal ultrasound-guided prostate biopsy. Age, prostate volume, DRE (normal or abnormal), biopsy findings (normal or report of PCa), PSA, free-to-total PSA, PSA density, testosterone and sex hormone-binding globulin (SHBG) were also prospectively recorded. Free and bioavailable testosterone were calculated using Vermeulens formula. Results. In the multivariate analysis, abnormal DRE [odds ratio (OR = 5.46, p < 0.001], SHBG levels ≥ 66.25 nmol/l [OR = 3.27; 95% confidence interval (CI) 1.52 to 7.04, p < 0.002] and bioavailable testosterone levels ≤ 104 ng/dl (OR = 4.92, 95% CI 1.78 to 13.59, p = 0.002) were related to the diagnosis of prostate adenocarcinoma. Age, free testosterone, PSA, testosterone, PSA/testosterone, PSA/free testosterone and PSA/bioavailable testosterone were not related to PCa diagnosis. Conclusions. Low bioavailable testosterone levels and high SHBG levels were related to a 4.9- and 3.2-fold risk of detection of PCa on prostate biopsy owing to PSA elevation or abnormal DRE. This fact may be useful in the clinical scenario in counselling patients at risk for PCa.

Air Cystoscopy is Superior to Water Cystoscopy for the Diagnosis of Active Hematuria

PURPOSE We evaluated the clinical use of air cystoscopy, including its possible advantages and disadvantages over water cystoscopy. MATERIALS AND METHODS Two independent observers prospectively studied consecutive patients who underwent water cystoscopy first and then air cystoscopy at our center from May to September 2012. The indication for rigid cystoscopy in the operating room was noted independently by either observer. Findings after rigid cystoscopy were correlated with the results of flexible water and air cystoscopy using the Pearson correlation and Student t-test. RESULTS Included in the study were 57 patients with active hematuria, of whom 36 had bladder cancer, and 257 with a history of bladder tumor. The cause of bleeding was clearly identified on water cystoscopy in 22 patients (38%), including tumors in 17 and prostate bleeding in 5, and by air cystoscopy in 49 (86%), including tumors in 32 and prostate bleeding in 17. For diagnosing bladder tumors air cystoscopy had higher sensitivity than water cystoscopy (88% vs 47%, p=0.003) and similar specificity (97% vs 100%, p=0.93). In the 295 patients without hematuria there was no difference in the indication compared to that identified on rigid cystoscopy (43 vs 43, p=1.0). Water cystoscopy revealed more small papillary tumors than air cystoscopy but the number was not significantly different (76 vs 67, p=0.26). All such implants identified on water cystoscopy alone were less than 2 mm. No complication specifically related to air cystoscopy was noted. CONCLUSIONS We found no statistical difference between water and air cystoscopy in patients without hematuria. Air cystoscopy had higher sensitivity and specificity for diagnosing active hematuria while adding almost no specific complications to the procedure.

Prior Lubrication of the Urethra Does Not Reduce Pain Perception in Men Undergoing Flexible Cystoscopy

Objective: The study aimed to test the hypothesis that the instillation of lidocaine gel does not reduce the pain related to flexible cystoscopy. Material and Methods: A prospective randomized study was designed to compare the pain perception between intraurethral instillation of lidocaine gel and saline solution in flexible cystoscopy. One hundred consecutive male patients attending for flexible cystoscopy were randomized to receive 10 ml of lidocaine gel or 10 ml of saline solution. Saline solution was also used for the irrigation pressure. Patients recorded their pain on a 10 cm Visual Analog Scale before and after the procedure. Patients also assessed whether the cystoscopy was more painful than the previous one. Statistical comparison was made using the t test for parametrical data and the Mann-Whitney U test for non-parametrical data. Results: Mean pain score in the lidocaine group was 0.67 ± 1.11 cm (range 0-5) compared to 0.55 ± 1.10 cm (range 0-5) in the saline solution group. Pain perception did not differ significantly between the 2 groups (mean difference 0.12 cm, 95% CI -0.32 to 0.55, p = 0.40). Conclusions: Prior lubrication of the urethra does not reduce the pain produced during flexible cystoscopy. The introduction of flexible cystoscopes under direct vision and with an irrigation pressure might guarantee sufficient comfort and the lubricant gel instillation could be avoided.

The Role of Surgery in Local Recurrences after Radical Cystectomy for Bladder Cancer

Introduction: Local recurrence (LR) after radical cystectomy (RC) for bladder cancer has a bad prognosis. Treatment options include chemotherapy, radiation therapy and surgical excision, but few data is available on the advantages of surgery for these patients. Patients and Methods: We evaluated our series of 8 selected patients who underwent surgery for locally recurrent bladder cancer after RC. Results: The median time to recurrence after cystectomy was 20.8 months. The complications rate and severity were not negligible. Pathology report confirmed urothelial carcinoma with negative margins in all patients. After LR treatment, 4 patients recurred locally for a second time and 3 developed distant metastasis. They all died after a median follow-up of 10.4 months. One patient remained disease free after 14 months. Conclusions: The prognosis of patients with LR is poor regardless of surgical treatment and reflects the aggressive biological nature of urothelial tumors.

Recent advances of natural orifice transluminal endoscopic surgery in urological surgery

Natural orifice transluminal endoscopic surgery designates a surgical procedure that utilizes one or more patent natural orifices of the body with the intention to puncture a hollow viscera in order to enter the abdominal cavity. First carried out at the beginning of the 2000s in experimental models, it can be considered the natural evolution of laparoscopy towards the ideal of scarless surgery, as the avoidance of a large abdominal scar is associated with better cosmetic results and better recovery. However, the technology currently available does not allow the performance of complete pure natural orifice transluminal endoscopic surgery procedures. The surgical tools used are not specially designed for this approach, so difficulties in retracting organs, bleeding control and clashing of instruments are the main obstacle surgeons face. For this reason, the current available technique is the so‐called hybrid approach, where a natural orifice approach is combined with some abdominal trocars, using the natural orifice as the exit door for the specimen removal. As not many comparative studies have been published evaluating the advantages of natural orifice transluminal endoscopic surgery in front of traditional laparoscopic surgery, a review of the history of natural orifice transluminal endoscopic surgery, and an assessment of the available evidence of this technique regarding renal and urological pelvic surgery are performed in this article.

Función eréctil después de cistectomía con preservación neurovascular

OBJECTIVES To study the utility of neurovascular preservation for postoperative erection in radical cystectomy. MATERIALS AND METHODS Retrospective analysis of 44 cystectomies performed at our center between January 2006-December 2009 in men <65 years. In 11 cases a neurovascular preservation was done. We analyzed age, BMI, indication for surgery, urinary diversion, use of i-PDE5 or alprostadil, and daytime and nighttime continence. Erection Hardness Score (EHS) was used to assess erectile function. RESULTS Spontaneous postoperative erectile function in preservation group was 44,4% EHS 4, 33,3% EHS 3 and 22,3% EHS 1 (achieving EHS 3 or 4 with alprostadil). In the non preservation group, 4,5% achieved EHS 4 spontaneously. The other 95,5% had EHS 0 (4,5% achieved EHS 3 with tadalafil 20 mg and 9% with intracavernous injections). Variables age (P=.001) and nerve-sparing surgery (P<.001) were related to postoperative erectile function recovery. In the multivariate analysis, nerve-sparing surgery remained statisticaly significant. CONCLUSIONS The functional results in preserving cystectomy are promising. The preservation should be considered in young patients without erectile dysfunction.

Perfil hormonal preoperatorio en pacientes sometidos a prostatectomía radical por cáncer de próstata

OBJECTIVE There is controversial evidence regarding preoperative testosterone (T) levels related to poor prognosis factors after radical prostatectomy (RP). The aim of this manuscript is to determine the relationship between preoperative T levels and final pathologic report together to biochemical recurrence after RP. MATERIALS AND METHODS We prospectively analysed 143 patients submitted to RP from February 2008 to June 2010 in our centre. Pretreatment T and sex hormone-binding globulin levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) T were calculated using Vermeulens formula. Low T levels were defined as 346 ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumour burden, Gleason score, multifocality and biochemical recurrence (using both PSA>0.4 ng/dL and PSA>0.2 ng/dL as cut-off values) was performed, according to preoperative levels of T. RESULTS Variables Gleason score, rate and number of positive margins, tumour burden, tumour multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T<346 ng/dL was not found to be related to PSA recurrence (PSA>0,4 ng/dL log-rank, P=.512), although a trend was observed when PSA>0,2 ng/dL (log-rank, P=.097). CONCLUSION Preoperative T levels were not related to final pathological report or to biochemical recurrence.