J.L.H. Ruud Bosch

Effect of testosterone supplementation on functional mobility, cognition, and other parameters in older men: a randomized controlled trial.

CONTEXT Serum testosterone levels decline significantly with aging. Testosterone supplementation to older men might beneficially affect the aging processes. OBJECTIVE To investigate the effect of testosterone supplementation on functional mobility, cognitive function, bone mineral density, body composition, plasma lipids, quality of life, and safety parameters in older men with low normal testosterone levels. DESIGN, SETTING, AND PARTICIPANTS Double-blind, randomized, placebo-controlled trial of 237 healthy men between the ages of 60 and 80 years with a testosterone level lower than 13.7 nmol/L conducted from January 2004 to April 2005 at a university medical center in the Netherlands. INTERVENTION Participants were randomly assigned to receive 80 mg of testosterone undecenoate or a matching placebo twice daily for 6 months. MAIN OUTCOME MEASURES Functional mobility (Stanford Health Assessment Questionnaire, timed get up and go test, isometric handgrip strength, isometric leg extensor strength), cognitive function (8 different cognitive instruments), bone mineral density of the hip and lumbar spine (dual-energy x-ray absorptiometry scanning), body composition (total body dual-energy x-ray absorptiometry and abdominal ultrasound of fat mass), metabolic risk factors (fasting plasma lipids, glucose, and insulin), quality of life (Short-Form Health 36 Survey and the Questions on Life Satisfaction Modules), and safety parameters (serum prostate-specific antigen level, ultrasonographic prostate volume, International Prostate Symptom score, serum levels of creatinine, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, hemoglobin, and hematocrit). RESULTS A total of 207 men completed the study. During the study, lean body mass increased and fat mass decreased in the testosterone group compared with the placebo group but these factors were not accompanied by an increase of functional mobility or muscle strength. Cognitive function and bone mineral density did not change. Insulin sensitivity improved but high-density lipoprotein cholesterol decreased; by the end of the study, 47.8% in the testosterone group vs 35.5% in the placebo group had the metabolic syndrome (P = .07). Quality-of-life measures were no different except for one hormone-related quality-of-life measure that improved. No negative effects on prostate safety were detected. CONCLUSION Testosterone supplementation during 6 months to older men with a low normal testosterone concentration did not affect functional status or cognition but increased lean body mass and had mixed metabolic effects. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN23688581.

Correlates for Erectile and Ejaculatory Dysfunction in Older Dutch Men: A Community‐Based Study

OBJECTIVES: We estimated correlates for erectile dysfunction (ED) (defined as a report of erections of severely reduced rigidity or no erections) and ejaculatory dysfunction (EjD) (defined as a report of ejaculations with significantly reduced volume or no ejaculations) in a large community sample of older men.

Erectile and ejaculatory dysfunction in a community-based sample of men 50 to 78 years old: prevalence, concern, and relation to sexual activity ☆

OBJECTIVES To determine the prevalence rates of erectile and ejaculatory dysfunction, associated bother, and their relation to sexual activity in a population-based sample of elderly men.Methods. Data were collected from 1688 men by way of self-administered questionnaires (including the International Continence Society male sex questionnaire) and measurements at a health center and urology outpatient department. RESULTS The prevalence of significant erectile dysfunction (ie, erections of severely reduced rigidity or no erections) increased from 3% in men 50 to 54 years old to 26% in men 70 to 78 years old. In the same age strata, the prevalence of significant ejaculatory dysfunction (ie, ejaculations with significantly reduced volume or no ejaculations) increased from 3% to 35%. Pain or discomfort during ejaculation was rare (1%) and independent of age. In general, men were more concerned about erectile dysfunction than about ejaculatory dysfunction. However, most men had no or only little concern about their dysfunction. The percentage of men who reported being sexually active declined with increasing age and was lower in men with erectile and ejaculatory dysfunction and in men without a partner. In sexually active men, 17% to 28% had no normal erections, indicating that with advancing age normal erections are not an absolute prerequisite for a sexually active life. CONCLUSIONS Erectile and ejaculatory dysfunction are common in elderly men. The results of this study indicate that these conditions are much less of a problem for older men than previously suggested.

The Prevalence and Causes of Nocturia

PURPOSE Nocturia is a troubling condition with implications for daytime functioning. However, it often goes unreported. Many prevalence studies exist but differences in populations and definitions of nocturia render assimilation of the data difficult. This review provides an overview of the nocturia prevalence literature. MATERIALS AND METHODS A PubMed search was performed to identify articles published in English from 1990 to February 2009 reporting nocturia prevalence in community based populations. Rates reported as overall data, and by age and by gender, were plotted for comparison. RESULTS A total of 43 relevant articles were identified. Prevalence rates in younger men (20 to 40 years) were 1 or more voids in 11% to 35.2% and 2 or more voids in 2% to 16.6%. Prevalence rates in younger women were 1 or more voids in 20.4% to 43.9% and 2 or more voids in 4.4% to 18%. In older men (older than 70 years) rates were 1 or more void in 68.9% to 93% and 2 or more voids in 29% to 59.3%. In older women rates were 1 or more void in 74.1% to 77.1% and 2 or more voids in 28.3% to 61.5%. Therefore, in practice up to 1 in 5 or 6 younger people consistently wake to void at least twice each night. In some studies younger women appeared more likely to be affected than men. Up to 60% of older people void 2 or more times nightly. CONCLUSIONS Nocturia is common across populations. It is most prevalent in older people but it also affects a significant proportion of younger individuals. Clinicians should be alert to the possibility that nocturia may impact the sleep, quality of life and overall health of their patients. Since the condition is highly multifactorial, frequency-volume charts are invaluable tools for the diagnosis of underlying factors and for treatment selection.

Different brain effects during chronic and acute sacral neuromodulation in urge incontinent patients with implanted neurostimulators

To compare changes in regional cerebral blood flow (rCBF), using positron emission tomography (PET), during chronic and acute sacral neuromodulation (SN). SN is an effective long‐term treatment for chronic urge incontinence due to urinary bladder hyperactivity, as sensory nerves, spinal and supraspinal structures are probably responsible for the action of SN. It is not known which brain areas are involved, and the optimum benefit of SN is not immediate, suggesting that induced plasticity of the brain is necessary.

In vivo bladder cancer diagnosis by high-volume Raman spectroscopy.

We studied the feasibility of Raman spectroscopy for the diagnosis of bladder cancer in vivo. Since the invasion stage is crucial for the treatment choice, a high-volume based Raman probe was used to investigate the potential of determining the invasiveness of bladder cancer. High quality spectra were obtained from suspicious and nonsuspicious bladder locations during the procedure of transurethral resection of bladder tumors (TURBT) with collection times of 1-5 s. Multivariate analysis was used to generate the classification models. The algorithm was able to distinguish bladder cancer from normal bladder locations with a sensitivity of 85% and a specificity of 79%. The Raman spectra of bladder cancer stages showed a gradual increase in the intensity of specific amino acid peaks and, most likely, an increase in the intensity of DNA peaks.

Long-Term Adherence to Antimuscarinic Therapy in Everyday Practice: A Systematic Review

PURPOSE Antimuscarinic drug treatment is known to have side effects and, consequently, poor adherence in therapeutic regimens. In this systematic review we study the long-term (greater than 6 months) adherence to antimuscarinic drugs in daily clinical practice, and identify factors contributing to poor adherence and persistence. MATERIALS AND METHODS This systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was performed using PubMed® and Embase™ using synonyms for incontinence, overactive bladder and antimuscarinics combined with synonyms for medication adherence. We chose to include only pharmaceutical database studies (using prescription/insurance claim data) and patient self-report studies, using established pharmacoepidemiological parameters such as persistence rate and medication possession rate. RESULTS A total of 1,245 titles were screened, of which 102 abstracts were assessed. Fourteen studies were ultimately included, comprising 190,279 unique patients (mean age 69.5 years). Regardless of which specific antimuscarinic drug is studied, persistence rates are usually poor. Considering all drugs together, median persistence rates were 12.0% to 39.4% (with an outlier of 75.5%) at 12 months, 8.0% to 15.0% at 18 months and 6.0% to 12.0% at 24 months. At 36 months persistence rates ranged from 0.0% (darifenacin) to 16.0% (trospium). Mean reported medication possession rates were also low, with a mean of 0.37 at 12 months. Risk factors for discontinuation were identified, with the most important being younger age group, use of oxybutynin and use of immediate release formulations. CONCLUSIONS Improvement in adherence and persistence with antimuscarinic medication should be an important goal in the development of new drugs for overactive bladder and urinary incontinence.

A systematic review and meta-analysis of the relationship between hospital/surgeon volume and outcome for radical cystectomy: an update for the ongoing debate.

CONTEXT There is an ongoing debate about centralisation of radical cystectomy (RC) procedures. OBJECTIVE To conduct a systematic review of the literature on the volume-outcome relationship for RC for bladder cancer (BCa) with consideration for the methodologic quality of the available evidence and to perform a meta-analysis on the studies meeting predefined quality criteria. EVIDENCE ACQUISITION A systematic search was performed to identify all articles examining the effects of procedure volume on clinical outcome for cystectomy. Reviews, opinion articles, and surveys were excluded. All articles were critically appraised for methodologic quality and risk of bias. Meta-analysis was performed to calculate the overall effect of higher surgeon or hospital volume on patient outcome. EVIDENCE SYNTHESIS Ten studies of good methodologic quality were included for meta-analysis. Eight studies were based on administrative data, two studies on clinical data. The results showed a significant association between high-volume hospitals and low mortality. A meta-analysis of the seven studies on hospital mortality showed a pooled estimated effect of odds ratio (OR) 0.55 (range: 0.44-0.69). The result was moderate heterogeneity (I(2)=50). A large variation in cut-off points used was observed. Sensitivity analyses did not show different effects in any of the subgroup analyses. Also, no significant differences in effect sizes were observed for different cut-off points. The data were not suggestive for publication bias. One study showed a positive effect of hospital volume on survival (hazard ratio [HR]: 0.89; p=0.06). Two studies showed a beneficial effect of surgeon volume on mortality (OR: 0.55; OR: 0.64). Only one study on the impact of surgeon volume on survival was found; it showed no significant positive effect for higher volume (HR: 0.83; p=0.26). CONCLUSIONS Postoperative mortality after cystectomy is significantly inversely associated with high-volume providers. However, additional quality criteria, such as infrastructure and level of specialisation, should be formulated to direct centralisation initiatives. The Dutch Association of Urology in 2010 implemented a national quality of care (QoC) registration programme for all patients treated by surgery for muscle-invasive BCa, including multiple parameters defining QoC.

Morbidity and Quality of Life in Patients with Orthotopic and Heterotopic Continent Urinary Diversion

OBJECTIVES To evaluate morbidity and quality of life (QOL) in patients with continent urinary diversion. METHODS Morbidity and neobladder function were analyzed in 56 consecutive patients with bladder substitutions. QOL assessment was performed using the Sickness Impact Profile (SIP), supplemented with a detailed voiding and continence questionnaire. RESULTS Mean age was 44.7 years. Mean follow-up was 41 months. Thirty-one men and 25 women were treated for transitional cell carcinoma (n = 22) or benign conditions (n = 34). In 33 patients, orthotopic (20 Mainz pouch and 13 ileal neobladder) substitutions were performed and in 23, heterotopic substitutions (Indiana pouch) were performed. Early complications required five open reinterventions. Late complications (at more than 3 months) included ureteric stenosis in 5 patients. In 38 patients (68%), full urinary continence was achieved. Spontaneous micturition was possible in 61% of orthotopic substitutions, whereas 15% of patients were required to perform intermittent catheterization only and 24% exhibited a combined voiding pattern. Compared to age-matched reference values, SIP scores showed a negative impact of heterotopic or orthotopic diversion in the SIP categories of emotion, recreation, and social interaction. The latter category included a statement about sexual activity, which was decreased in 50% of patients. In the category of emotion, orthotopic substitutions compared favorably to heterotopic substitutions (P = 0.02). CONCLUSIONS The morbidity profile is comparable to previous reports. QOL assessment using the SIP revealed a minor advantage for an orthotopic placement which was due to a relatively small number of patients. Most importantly, QOL was found to be favorable for both types of bladder substitute placement.

Comparing Three Different Techniques for Magnetic Resonance Imaging-targeted Prostate Biopsies: A Systematic Review of In-bore versus Magnetic Resonance Imaging-transrectal Ultrasound fusion versus Cognitive Registration. Is There a Preferred Technique?

CONTEXT The introduction of magnetic resonance imaging-guided biopsies (MRI-GB) has changed the paradigm concerning prostate biopsies. Three techniques of MRI-GB are available: (1) in-bore MRI target biopsy (MRI-TB), (2) MRI-transrectal ultrasound fusion (FUS-TB), and (3) cognitive registration (COG-TB). OBJECTIVE To evaluate whether MRI-GB has increased detection rates of (clinically significant) prostate cancer (PCa) compared with transrectal ultrasound-guided biopsy (TRUS-GB) in patients at risk for PCa, and which technique of MRI-GB has the highest detection rate of (clinically significant) PCa. EVIDENCE ACQUISITION We performed a literature search in PubMed, Embase, and CENTRAL databases. Studies were evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 checklist and START recommendations. The initial search identified 2562 studies and 43 were included in the meta-analysis. EVIDENCE SYNTHESIS Among the included studies 11 used MRI-TB, 17 used FUS-TB, 11 used COG-TB, and four used a combination of techniques. In 34 studies concurrent TRUS-GB was performed. There was no significant difference between MRI-GB (all techniques combined) and TRUS-GB for overall PCa detection (relative risk [RR] 0.97 [0.90-1.07]). MRI-GB had higher detection rates of clinically significant PCa (csPCa) compared with TRUS-GB (RR 1.16 [1.02-1.32]), and a lower yield of insignificant PCa (RR 0.47 [0.35-0.63]). There was a significant advantage (p = 0.02) of MRI-TB compared with COG-TB for overall PCa detection. For overall PCa detection there was no significant advantage of MRI-TB compared with FUS-TB (p=0.13), and neither for FUS-TB compared with COG-TB (p=0.11). For csPCa detection there was no significant advantage of any one technique of MRI-GB. The impact of lesion characteristics such as size and localisation could not be assessed. CONCLUSIONS MRI-GB had similar overall PCa detection rates compared with TRUS-GB, increased rates of csPCa, and decreased rates of insignificant PCa. MRI-TB has a superior overall PCa detection compared with COG-TB. FUS-TB and MRI-TB appear to have similar detection rates. Head-to-head comparisons of MRI-GB techniques are limited and are needed to confirm our findings. PATIENT SUMMARY Our review shows that magnetic resonance imaging-guided biopsy detects more clinically significant prostate cancer (PCa) and less insignificant PCa compared with systematic biopsy in men at risk for PCa.