Human comfort: more than modern medical technology.
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Emotions↗
Biomedical subjects
S A Kaplan
Publications and source records attributed to S A Kaplan.
Use of prostatic stents for the treatment of benign prostatic hyperplasia in high-risk patients.
Benign prostatic hyperplasia (BPH) is a frequent disease in men and a major cause of lower urinary tract symptoms (LUTS). Transurethral resection of the prostate (TURP) or open surgery remains the gold standard of treatment for symptomatic BPH. However, 10% to 15% of patients with BPH cannot undergo surgery due to grave concomitant diseases. For patients presenting with contraindications to surgery or anesthesia, several minimally invasive alternative treatment modalities are available. One such therapeutic alternative is prostatic stenting, which can serve as a temporary or permanent solution for bladder outlet obstruction caused by BPH. Although not a new concept, this is a relatively new treatment modality in the United States, primarily because of the strict regulatory forces governing the use of these devices. Prostatic urethral stents have been widely demonstrated to be safe and effective for the treatment of symptomatic BPH. In addition to being minimally invasive, prostatic stenting is generally rapid, easy to perform, immediately effective, and has a low cost compared with conventional surgical treatment. Prostatic stents are therefore well suited to treat the frail elderly patient who would not be able to withstand the stress of undergoing surgery. This report reviews the current use of prostatic urethral stents in the treatment of high-risk surgical patients with BPH.
Age Factors↗
Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia.
OBJECTIVES: To compare the efficacy and safety of finasteride 5 mg in older (65 years old or older) versus younger (45 to younger than 65 years old) men with benign prostatic hyperplasia (BPH). METHODS: The Proscar Long-Term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men 45 to 78 years old with symptomatic BPH, enlarged prostates, and no evidence of prostate cancer. The endpoints included urinary symptoms, prostate volume, occurrence of acute urinary retention and/or BPH-related surgery, and safety. RESULTS: In both age cohorts, finasteride treatment led to a 51% reduction (P <0.001) in the relative risk for acute urinary retention and/or BPH-related surgery, a significant (P <0.001) and durable improvement in symptom score, and a significant (P <0.001) and sustained reduction in prostate volume. Within each age cohort, no significant differences were found between the placebo and finasteride-treated patients in the incidence of cardiovascular adverse events. Significant differences were evident between the placebo and finasteride groups in the incidence of the typical, known, drug-related adverse events, but no specific differences were associated with age. No drug interactions of clinical importance were observed in the finasteride-treated patients. CONCLUSIONS: The present analysis from PLESS demonstrates that in both older (65 years old or older) and younger men with symptomatic BPH and enlarged prostates, finasteride is highly effective in improving symptoms and reducing prostate volume in many men and in reducing the risk of acute urinary retention and BPH-related surgery. In addition, the safety profile of finasteride in both older and younger men is similar and no drug interactions of clinical importance were observed.
Aged↗
5alpha-reductase inhibitors: what role should they play?
The development of finasteride (PROSCAR, Merck & Co., Whitehouse Station, NJ) for the treatment of benign prostatic hyperplasia (BPH) has had variable results. Numerous short-term and long-term studies comparing finasteride with placebo have been reported. The results suggest that, physiologically, treatment with finasteride significantly decreases levels of both serum and intraprostatic dihydrotestosterone about 70% to 80% from baseline. In addition, total gland size decreases significantly-about 15% to 25% from baseline-particularly in the area of the periurethral zone of the prostate after finasteride treatment. Baseline prostate size has been found to have a relation to efficacy of finasteride treatment. The larger the prostate at baseline, the greater the urinary flow rate increase and symptom score decrease compared with placebo. Health-related quality-of-life parameters improved in those taking finasteride. In studies evaluating combination therapy, no significant differences were noted between those treated with an alpha blocker, such as terazosin or doxazosin in combination with finasteride, and those receiving an alpha blocker alone. Long-term finasteride versus placebo studies, such as the PROSCAR Long-Term Efficacy and Safety Study (PLESS), suggest that long-term medical therapy with finasteride affects the natural history of the disease as manifested by the decrease in rates of acute urinary retention and surgery. In patients who are "therapeutic responders," the degree of symptomatic improvement in those treated with finasteride appears to be equal to that seen in patients receiving alpha blockers. Prostate cancer detection rates did not differ between those treated with finasteride and those receiving a placebo. The results of these studies suggest that physicians must evaluate what role finasteride plays in the spectrum of available options for the treatment of BPH and lower urinary tract symptoms. Baseline parameters, such as prostate volume, prostate-specific antigen values, and whether to administer finasteride in combination with alpha blockers, are among the factors that will determine the appropriateness of such therapy.
5-alpha Reductase Inhibitors↗
Introduction.
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5-alpha Reductase Inhibitors↗
Holmium and interstitial lasers for the treatment of benign prostatic hyperplasia: a laser revival.
With the introduction of the side-firing neodymium:yttrium-aluminum-garnet laser in the early 1990s laser prostatectomy became a widely used treatment for benign prostatic hyperplasia. However, because of prolonged postoperative catheterization times, the lack of immediate effect, and severe postoperative dysuria, many urologists became disinterested in this procedure. Recently, as a result of advances in laser technology, namely, the holmium laser and interstitial laser prostatectomy, interest in lasers for the treatment of benign prostatic hyperplasia has been rekindled. This paper will review published reports over the past year regarding these relatively new treatments.
Clinical Trials as Topic↗
Biomarker analysis demonstrates a hypoxic environment in the castrated rat ventral prostate gland.
Within the first 24 h after castration of an adult male rat, the vascular system of the ventral prostate gland undergoes a degenerative process that drastically reduces blood flow to the tissue. Since the vascular degeneration precedes the loss of the prostatic epithelium (by apoptosis), we have proposed that the onset of epithelial cell apoptosis in this tissue is caused by an ischemic/hypoxic environment resulting from the loss of blood flow. In order to further evaluate the extent to which ischemia/hypoxia might be a factor in apoptosis of the prostate epithelium after castration, we analyzed for biomarkers of cellular hypoxia in rat ventral prostates during the first 3 days following castration. Ventral prostate tissues removed from hypoxyprobe-1-treated adult male rats (uncastrated controls; surgically castrated for 24, 48 or 72 h, or sham-castrated for equivalent times) were directly analyzed for evidence of hypoxia by in situ immunohistochemical evaluation of hypoxyprobe-1 adduct formation in the prostate cells. Protein extracts from these tissues were also tested for expression of the 120 kDa hypoxia-inducible factor-1-alpha (HIF-1-alpha) protein as well as for expression of mitogen-activated protein kinase (MAPK) and c-Jun N-terminal kinase (JNK) proteins using a Western blot assay. The tyrosine phosphorylation status of the latter signaling molecules was also evaluated by Western blotting using anti-tyrosine phosphate antibodies. Our results showed that epithelial cells of the rat ventral prostate stained positively for hypoxyprobe-1 adducts at all times after castration, whereas cells in control tissues were unstained by this procedure. In addition, the prostatic expression of HIF-1-alpha protein was increased approximately 20-fold at 48 h after castration compared to control tissues. Finally, although prostatic MAPK and JNK protein expression was unaltered during the early period after castration, phosphorylation of the JUN kinase protein was significantly elevated, indicating that this stress-activated cellular signaling pathway becomes more active subsequent to castration. These results support our proposal that early castration-induced degeneration and constriction of the vascular system of the rat ventral prostate gland leads to reduced oxygenation of prostatic epithelial cells and the activation of hypoxic cellular signaling in these cells through upregulation of HIF-1-alpha expression and stimulation of the JUN kinase signaling pathway.
Animals↗
Acute increase in blood flow to the rat bladder subsequent to partial bladder outlet obstruction.
Partial obstruction of the rat bladder outlet initiates a multi-step process during which the bladder progressively loses its functional ability. The first step in this progression is bladder hypertrophy; the organ dramatically increases in size and weight to compensate for the effects of obstruction. Unoperated female rats, age-matched, sham-obstructed rats, and rats that received a partial bladder outlet obstruction were studied. During the first 24 hours after partial bladder outlet obstruction, relative bladder blood flow was measured using a fluorescent microsphere infusion technique and laser Doppler imaging. Nitric oxide synthase (NOS) activities of control and obstructed rat bladder tissues were determined using an enzymatic assay that measures the conversion of (3)H-L-arginine to (3)H-L-citrulline. Using the microsphere infusion technique, a significant increase in blood flow to the obstructed rat bladder was observed during the first 24 hours after partial bladder outlet obstruction. Relative bladder blood flow increased approximately sixfold at 4 and 6 hours post-obstruction and remained elevated through 24 hours of obstruction. Sham operations (evaluated after 6 hours after surgery) resulted in a minor increase in blood flow that did not reach statistical significance. Relative blood flow to the spleen, measured in the same rats, was not significantly changed. Laser Doppler measurements also identified a significant increase in rat bladder blood flow after outlet obstruction and showed that increased blood flow could be detected as early as 1 hour post-obstruction. Interestingly, despite the significant differences in bladder blood flow between control and early post-obstructed rat bladders, NOS activities of control and obstructed rat bladders were comparable. The increase in bladder blood flow precedes the urothelial, fibroblast and smooth muscle cell hyperplasia, and the smooth muscle hypertrophy that occurs after obstruction. We propose that, in response to surgical induction of partial outlet obstruction, acute up-regulation of bladder blood flow may be an initiating factor for subsequent bladder cell proliferation and smooth muscle hypertrophy. Neurourol. Urodynam. 19:195-208, 2000.
Animals↗
Current Urology Reports--what makes us different?
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Periodicals as Topic↗
Benign prostatic hyperplasia: many new options, same old approach.
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Humans↗
Transurethral vaporization of the prostate: current techniques.
Electrovaporization has quickly become a popular procedure for treating benign prostatic hyperplasia. By using standard transurethral electrosurgical technology, electrovaporization offers standard transurethral loop-like resection and transurethral prostatectomy (TURP)-like efficacy with less morbidity than that associated with TURP. Through a combination of two electrosurgical effects (vaporization and desiccation), electrovaporization ablates significant volumes of prostatic tissue with each passage of the electrode. Newly designed thicker loop electrodes have led to a modification of the original electrovaporization technique. "Vaporizing-resection" adds the advantages of transurethral resection to those of electrovaporization with the use of one electrode. Very large glands can be treated efficiently, and prostatic tissue specimens are produced. Moreover, additional vaporization of tissue occurs with minimized bleeding. This report reviews basic electrosurgical principles, electrode design, and factors that affect vaporizing efficiency. Current long-term data on electrovaporization compared with TURP are summarized, and pilot studies evaluating vaporizing- resection have shown promising results. A new technology that has entered the market--bipolar electrovaporization--is also discussed. Finally, combination therapy and Columbia's 4-year experience with vaporization techniques are discussed.
Combined Modality Therapy↗
Benign prostatic hyperplasia: challenges for the new millennium.
The understanding and therapy of benign prostatic hyperplasia (BPH) has become more complex recently. The molecular mechanisms and growth factors involved in BPH need to be elucidated in the new millennium. The current classification of disease reflects the varied pathophysiologic mechanisms causing lower urinary tract symptoms (LUTS). In addition, symptom scores have improved evaluation of men with BPH, yet 'bother' and 'health-related quality of life' should be better recognized as significant outcome parameters. Clinical evaluation with laboratory markers specific for BPH or LUTS is currently inadequate. Yet, urodynamic evaluation should remain an important aspect of evaluation to guide selection of therapy. Recently medical therapy has expanded to include uroselective alpha blockade and phytotherapy, yet more research is needed. The most significant growth in the field, however, is in minimally invasive therapies of the prostate. Long-term comparative prospective multicenter studies are needed to properly evaluate the outcomes of new technologies compared to traditional procedures that are considered standard of care.
Humans↗
Detrusor contraction duration may predict response to alpha-blocker therapy for lower urinary tract symptoms.
OBJECTIVES: Baseline pressure/flow parameters have not correlated well with response to medical therapy for lower urinary tract symptoms (LUTS). This open-label, nonrandomized retrospective study was designed to evaluate whether the urodynamic parameter duration (in seconds) of the detrusor contraction (DCD) correlates better with alpha-blocker response than previously described urodynamic parameters. METHODS: 93 men (mean age 62.6+/-8.5) with LUTS underwent urodynamic evaluation prior to initiating therapy with doxazosin titrated to 8 mg and followed for 6 months. Parameters of evaluation included the AUA symptom score (AUASx), peak urinary flow rate (Q(max)), maximal detrusor pressure (P(max)), detrusor pressure at maximal flow (P(det)) and DCD. The correlation and predictive value of therapeutic response and baseline urodynamic parameters were assessed. RESULTS: 85 patients were evaluable at 6 months. For the entire group, AUASx decreased from 15.1+/-6.9 to 9.7+/-5.1 (-36%) and Q(max) increased from 9.3+/-3.7 to 11.9+/-5.7 ml/s (+28%). Baseline P(max) was 74.8+/-19.6 cm H(2)O, P(det) was 61.6+/-18.9 cm H(2)O and DCD was 107.6+/-28.6 s. There was weak correlation between either baseline P(max) or P(det) and therapeutic response (defined as a decrease in AUASx of 40% and an increase in Q(max) of 30%). Utilizing a baseline DCD of 90 s or more, there was a significant correlation to therapeutic response (r = 0.48, p = 0.002). CONCLUSIONS: These preliminary data suggest that DCD may be a useful urodynamic parameter to predict and optimize therapy with a-blockade. The potential utility and cost-effectiveness of DCD remains to be determined.
Adrenergic alpha-Antagonists↗
Prospective analysis of 373 consecutive women with stress urinary incontinence treated with a vaginal wall sling: the Columbia-Cornell University experience.
PURPOSE: We compare the efficacy and morbidity of 373 consecutive women who underwent a vaginal wall sling for stress urinary incontinence due either to anatomical incontinence or intrinsic sphincter deficiency. To our knowledge this series is the largest prospective database on surgical management of stress urinary incontinence in the urological literature. MATERIALS AND METHODS: Preoperative evaluation included history, voiding diary, physical examination, cystoscopy, pad count and video urodynamic study. Outcome measures included postoperative presence of incontinence secondary to either stress and/or detrusor instability, number of pads used, complications, operating time, length of suprapubic catheterization, length of hospitalization and loss of work days. RESULTS: A total of 373 consecutive women 18 to 85 years old (mean age 55.7) were followed for a mean of 39.8 months. Of these patients 183 (49%) presented with anatomical incontinence and the remaining 190 (51%) had intrinsic sphincter deficiency. Preoperative detrusor instability was present in 60 (33%) patients with anatomical incontinence and 68 (36%) with intrinsic sphincter deficiency. Postoperatively, 14 patients (4%) had recurrent stress urinary incontinence. De novo detrusor instability and urge incontinence were noted in 30 women (8%), and was persistent in 22 (6%). There was no correlation between the diagnosis of anatomical incontinence or intrinsic sphincter deficiency and persistent stress urinary incontinence or detrusor instability. Daily pad use was decreased from 4.3 to 0.5 and from 4.6 to 0.4, respectively, for patients with anatomical incontinence and intrinsic sphincter deficiency. Operating time, catheter duration, length of hospital stay and days lost from work for patients with anatomical incontinence (33.3 +/- 14.3 minutes, 4.7 +/- 1.1 days, 0.9 +/- 0.7 days and 11.3 +/- 2.9 days, respectively) were similar to patients with intrinsic sphincter deficiency (38.4 +/- 17.8, 4.6 +/- 0.9, 1.1 +/- 0.7, 12.4 +/- 4.7). The most common complications were urinary tract infection (3%), wound infection (4%) and pelvic organ prolapse (7%). CONCLUSIONS: The results of this large database suggest that the vaginal wall sling is effective for the management of stress urinary incontinence. Efficacy, morbidity and reduced hospitalization time were similar for patients with either anatomical incontinence or intrinsic sphincter deficiency and independent of surgeon experience.
Adolescent↗
Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction.
OBJECTIVES: Sildenafil has been demonstrated to be safe and effective in the treatment of men with erectile dysfunction. The role of sildenafil in treating women with sexual dysfunction has heretofore not been reported. The purpose of this preliminary study was to ascertain the response of postmenopausal women with self-described sexual dysfunction treated with sildenafil for 3 months. METHODS: Thirty-three consecutive postmenopausal women with sexual dysfunction based on history were entered in this open-label, nonrandomized study. All patients received 50 mg of sildenafil. Efficacy was assessed at weeks 4, 8, and 12 using a newly developed 9-item, self-administered Index of Female Sexual Function (IFSF) and a global efficacy question ([GEQ] Did treatment improve your sexual function?). The IFSF quantifies the domains of desire, quality of sexual intercourse, overall satisfaction with sexual function, orgasm, lubrication, and clitoral sensation. RESULTS: Of the group, 30 women (91 %) completed the study and were available for follow-up at 3 months. Mean baseline IFSF score before therapy was 24.8+/-9.8. Mean usage of sildenafil was 3.1+/-1.4 times per week for the duration of the study. The IFSF score improved to 29.5+/-7.6, 30.3+/-8.5, and 31.4+/-10.4 at 4, 8, and 12 weeks, respectively (P = 0.25). Mean scores for questions 2 (lubrication), 8 (orgasm), and 9 (clitoral sensation) improved by 23.2%, 7.4%, and 31.3%, respectively, at 12 weeks. Seven women (21%) noted improvement on the GEQ. Overall, only 6 (18.1%) of 33 patients had a significant (more than 60% improvement in IFSF score) therapeutic response. Clitoral discomfort and "hypersensitivity" occurred in 7 women (21%), 3 of whom withdrew from the study. Other side effects, which did not result in withdrawal from the study, included headache (n = 5), dizziness (n = 4) and dyspepsia (n = 3). CONCLUSIONS: The data suggest that sildenafil is well tolerated in postmenopausal women with sexual dysfunction. Overall sexual function did not improve significantly, although there were changes in vaginal lubrication and clitoral sensitivity. The role of sildenafil in treating sexual dysfunction in various cohorts of women remains to be determined.
Adult↗
Uroselective alpha-blockade for benign prostatic hyperplasia: clinically significant or marketing savvy?
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Adrenergic alpha-Antagonists↗
Interstitial thermometry in men undergoing electrovaporization of the prostate.
BACKGROUND AND OBJECTIVES: Transurethral electrovaporization of the prostate (TVP) has been utilized increasingly in the therapeutic management of benign prostatic hyperplasia (BPH). The temperature profile within both prostatic and periprostatic tissue has been presented as a parameter of safety in various preliminary studies. This prospective study measured interstitial temperature during TVP in both the prostate and the surrounding tissue of 18 men. METHODS: These 18 men undergoing TVP had three interstitial thermocouple probes placed under ultrasound guidance. Probes were positioned in the rectal wall and at the 5 and 7 o'clock position of the prostate capsule. A fourth probe was placed within 1 mm of the area of vaporization to determine "lesion" temperature. Temperature was measured at baseline and at 15-minute intervals as TVP was performed utilizing the VaporTrode at 240 to 280 W with a Valley Lab Force 40 generator. RESULTS: The maximum temperature variability was 1.9 degrees C. The temperature within 0.5 mm of the area of vaporization was >100 degrees C. These results were independent of the temperature of the irrigating solution. CONCLUSIONS: These results provide compelling evidence that high vaporization temperatures do not affect surrounding prostatic tissue. In theory, the risk of injury to either the rectum or the neurovascular bundle during TVP should be extremely low.
Aged↗
Laser prostatectomy: checkup on the promises.
Voiding symptoms caused by benign prostatic hyperplasia are responsible for significant compromise in the quality of life of many men. As our population ages, more men are seeking medical evaluation and treatment for this condition. In addition, with the recognition that this benign condition rarely creates significant life-threatening medical problems, there has been a movement toward less invasive therapies that are associated with the least possible iatrogenic morbidity. Among the currently available, minimally invasive techniques is laser prostatectomy. Is it standing up to its rival, transurethral resection of the prostate, or lagging behind?
Journal Article↗