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Urology

Volume 8, No 4 - Fall 2006

Volume 8, No 4 - Fall 2006

Table of Contents

Prostate Biopsy: Targeting Cancer for Detection and Therapy Technology Update
Despite improvements in cancer detection, prostate biopsy still lacks the ability to accurately map locations of cancer within the prostate. Improvements in prostate imaging may allow more accurate mapping of overall disease volume. Magnetic resonance (MR) spectroscopy allows improved specificity in detecting even small foci of disease within the peripheral zone. Improvements in MR-guided biopsy techniques may allow this technology to be adapted to therapeutics as well. Computer modeling of individual prostates serves as a means of designing optimized plans for prostate biopsy. The use of novel targeted biopsy schemes may allow an integration of available technologies in detection and localization of prostate cancer. Computer-directed needle biopsies based on anatomic landmarks within the prostate and computerized three-dimensional reconstruction of the gland may allow a highly reproducible means of identifying small foci of cancer, targeting them for therapy, and monitoring for recurrence. The TargetScan® system (Envisioneering Medical Technologies, St. Louis, MO) is the first technology to integrate available targeting methodologies in a systematic fashion. [Rev Urol. 2006;8(4):173-182]
The Role of Gonadotropin- Releasing Hormone Antagonists for the Treatment of Benign Prostatic Hyperplasia Treatment Update
Medical therapy is the preferred first-line approach in the management of lower urinary tract symptoms in men with benign prostatic hyperplasia. The magnitude of the improvement in lower urinary tract symptoms observed in response to combination therapy (-blocker plus 5- reductase inhibitors) does not approach that achieved with prostatectomy. Various drugs have been under consideration, including BXL628, lonidamine, and phosphodiesterase inhibitors, all of which have had unacceptable side effects. The gonadotropinreleasing hormone antagonist cetrorelix is associated with dose-dependent symptom improvement and reduction of prostate volume. Elucidating the mechanism for cetrorelix-mediated improvement in lower urinary tract symptoms will likely contribute to unraveling the pathophysiology of lower urinary tract symptoms in men. [Rev Urol. 2006;8(4):183-189]
Diagnostic Utility of the ImmunoCyt/uCyt+ Test in Bladder Cancer Diagnostic Update
Bladder cancer is a common malignancy in the United States. Although urine cytology is a useful adjunct in both diagnosis and follow-up and is highly sensitive for detecting high-grade tumors, it is limited by decreased sensitivity in detecting low-grade tumors, which constitute the majority of new diagnoses. Additional screening tests with high sensitivity and specificity for urothelial tumors of all grades are indicated to help improve the diagnostic ability of urine cytology as well as to reduce the need for frequent cystoscopies, especially in those with low-risk disease. Several assays have been developed, with the ImmunoCyt/uCyt test (DiagnoCure, Inc., Québec, Canada) being especially promising. Recent studies on the applicability and efficacy of ImmunoCyt/uCyt testing are reviewed, as are its sensitivity, specificity, and predictive value in the follow-up and screening of urothelial malignancies. [Rev Urol. 2006;8(4):190-197]
Botulinum Toxin for the Treatment of Idiopathic and Neurogenic Overactive Bladder: State of the Art Treatment Update
The pharmacologic treatment of overactive bladder and detrusor overactivity, whether idiopathic or neurogenic, has centered around blocking muscarinic receptors on the detrusor muscle. Although newer agents have been developed with better tolerability and safety, the basic mechanism by which the “irritable” detrusor is treated has not changed in decades. Although effective in many cases of idiopathic and neurogenic detrusor overactivity and overactive bladder, antimuscarinic agents fall short in many other cases because of lack of efficacy and/or tolerability. For the past several years, there has been increasing evidence to support the use of botulinum toxin for the treatment of detrusor overactivity and overactive bladder syndrome not effectively treated by anticholinergics. From early open-label studies to the more recent randomized, controlled trials, efficacy and tolerability data have been very encouraging. Botulinum toxin is not yet approved by the US Food and Drug Administration for the treatment of detrusor overactivity and overactive bladder, but the positive results seen thus far cannot be ignored. [Rev Urol. 2006;8(4):198-208]
Penile Rehabilitation After Radical Prostatectomy: Important Therapy or Wishful Thinking? Management Update
On the basis of data accumulated thus far, it is reasonable to discuss the implementation of a “penile rehabilitation” program with patients undergoing radical prostatectomy. Central to discussions of penile rehabilitation after radical prostatectomy is evidence demonstrating significant fibrotic changes in the corpus cavernosum that occur postoperatively. Several studies have been published evaluating the efficacy of various pro-erectogenic agents. The limited data regarding intracavernous injections and vacuum constriction devices suggest that an increased percentage of treated patients experienced a return of natural erections compared with patients who received no treatment. Longer, prospective, randomized, placebo-controlled studies will be needed to confirm the utility of these treatments. Data from contemporary studies evaluating the chronic use of oral phosphodiesterase type 5 inhibitors suggest a beneficial effect on endothelial cell function among men suffering from erectile dysfunction due to a variety of causes. Limited data suggest that this effect might be seen among post-prostatectomy patients, implying a possible role for these agents in enhancing the return of sexual function in such individuals. [Rev Urol. 2006;8(4):209-215]
Advances in the Treatment of Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia Meeting Review
Highlights from the 21st European Association of Urology Congress, April 5–8, 2006, Paris, France [Rev Urol. 2006;8(4):216-225]
Robotic Ureterolysis, Retroperitoneal Biopsy, and Omental Wrap for the Treatment of Ureteral Obstruction Due to Idiopathic Retroperitoneal Fibrosis Case Review
Retroperitoneal fibrosis (RPF) is a rare disorder of unclear etiology characterized by chronic inflammation of the retroperitoneum, which can involve any of the retroperitoneal structures, most notably the ureters, aorta, and vena cava. Historically, open biopsy, ureterolysis, and transpositioning or omental wrapping of the involved ureter(s) have been the preferred surgical treatments of RPF, with success rates greater than 90%. More recently, successful laparoscopic biopsy, ureterolysis, and ureteral omental wrapping and intraperitonealization have been described. We report the first case in the literature of idiopathic RPF managed with robotic ureterolysis and laparoscopic omental ureteral wrapping. [Rev Urol. 2006;8(4):226-230]
Fertility Reviewing the Literature