22 Nov 2011
A clinical diagnosis of benign prostatic hyperplasia (BPH) appeared to be associated with an increased risk of prostate cancer, in a large cohort study. However, the authors caution that this does not mean that the association is causal. This study, while impressive in size and duration, can be criticised on a number of counts. First, with regards to prostate cancer incidence it is not clear if the authors were able to exclude convincingly so-called ‘ascertainment bias’, the concept that men with BPH would be more thoroughly investigated/screened for prostate cancer, thus increasing incidence rates. Second, the study defined a prostate cancer death as a diagnosis of prostate cancer as the first, second or third listed cause of death on the death certificate. Therefore, a patient with BPH who had incidental prostate cancer discovered on PSA screening but died from an MI would be listed as a prostate cancer death, but a man without BPH with undiagnosed coincidental prostate cancer who also died from an MI would be classified as a non-prostate cancer death. Many patients present to their GP with lower urinary tract symptoms as a result of benign disease because of their belief, encouraged by the lay media, that these symptoms are due to prostate cancer. Most GPs will have been asked by patients with BPH if they have, or are at risk of, developing prostate cancer. The orthodox answer to this is that there is no convincing evidence of a link between these two common conditions, but it is a hugely complex link to study and there is therefore no firm evidence that there is not a link.'
20 Oct 2011
A long-term prospective study from Scotland has concluded that transurethral resection of the prostate (TURP) does not damage erectile function. However, there is an important proviso in this study. Dr Jonathan Rees comments: 'While this was a prospective study with good long-term follow-up, there was a significant drop off in the number of patients completing the study, from 280 at baseline, down to 113 at 12 years. This could clearly lead to significant attrition bias, potentially in either direction with the possibility that drop out was due to sexual inactivity/ED or alternatively because of successful sexual function. Patients will often ask their GP whether TURP will adversely affect sexual function. What should we tell them? First, that there is not good evidence, but overall we suspect that in those with good sexual function preoperatively, the risk of postoperative ED is relatively low. We should proactively use any consultation with a patient with BPH to check that they have been asked about co-existing ED and offered treatment where appropriate. Medical therapy for ED with phosphodiesterase inhibitors has also been shown to have a significant beneficial impact on LUTS.'
20 Sep 2011
Finasteride and dutasteride appear to have similar efficacy in benign prostatic hyperplasia (BPH) over 12 months, a head-to-head study has shown. Dr Rees, in this review of the study, comments: 'Finasteride is now off patent and the generic version is therefore considerably cheaper to prescribe than dutasteride. Studies such as COMBAT have shown the prolonged benefit of 5-ARIs at least up to five years, and thus the major limitation of this study is its relatively short duration of 12 months. 5-ARIs should be considered to be long-term therapy, and thus longer follow-up of these two arms would be of even greater interest. Long-term studies of combination therapy with finasteride and tamsulosin versus dutasteride and tamsulosin would also be of great clinical interest.'
09 Aug 2011
The increasing use of medical therapy as first-line treatment for BPH has resulted in a significant drop in transurethral prostatectomies (TURPs) being carried out. Researchers from Ontario, Canada, examined the records of patients undergoing TURP for symptomatic BPH at their hospital in 1988, before medical therapy had been introduced, 1998 when it had become an important option and 2008 when it had become first-line therapy. TURP rates dropped by 60% between 1988 and 1998 from 157 to 64. In the following 10 years, a moderate increase in TURP rates was seen with 84 procedures carried out in 2008. However, the population served increased from 64,000 to 88,000 over the time period studied. In 1988, none of the men undergoing TURP were recorded as being on any medical treatment for BPH, but this had increased to 36% in 1998 and 87% in 2008. The most common form of medical treatment in 1998 was alpha-blocker monotherapy, but in 2008 it was combination therapy with an alpha-blocker and 5-alpha reductase inhibitor.
22 Jun 2011
PSA testing has not increased in general practice in the UK despite raised public awareness and highly publicised research findings. Older men and men living in more affluent areas were most likely to be tested, a practice-based study has found. Retrospective data were analysed for the year 2007, for all men aged 45-89 years in 87 GP surgeries taking part in a larger prostate cancer study. These practices were distributed across the country in Bristol, Cambridge, Leicester, Sheffield, Leeds and Newcastle. Information was obtained on 126,716 men with no previous diagnosis of prostate cancer. 'The study concludes, that the UK has not seen a continued increase in rates of PSA testing, as previously seen in the late 1990s, and that testing rates are significantly lower than those in many other European countries and the US. Uptake of testing remains low in the UK with significant skew towards older, more affluent men. Clearly, current national policy of an informed choice for all men is not working and this study reinforces the need for more robust guidance.'
20 Apr 2011
Giving 5-alpha reductase inhibitors (5-ARIs) to men with low-risk prostate cancer undergoing active surveillance was associated with a lower rate of pathologic progression in a small retrospective cohort study. Men on 5-ARIs also had a longer median time to disease progression and were less likely to abandon active surveillance for active treatment. 'This study has limitations, in terms of a retrospective design with small numbers, but it paves the way for the REDEEM study, a large randomised controlled trial on the use of dutasteride in this setting.'
23 Mar 2011
Silodosin, a new alpha-blocker, shows promise in the treatment of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). A total of 955 men, aged >50 years, with LUTS caused by BPH were randomised (2:2:1) to receive either silodosin 8 mg, tamsulosin 400 µg or placebo for a 12-week period following a 4-week placebo run in. Importantly, the study was powered to show superiority of silodosin to placebo, but only non-inferiority to tamsulosin. Response was measured in terms of change from baseline in International Prostate Symptom Score (IPSS), storage and voiding subscores, quality of life due to urinary symptoms and maximum urinary flow rate (Qmax). Silodosin is super-selective for the α1A receptor (50 to 100 times more selective) which should in theory mean that it is better tolerated in terms of cardiovascular side effects, and even more efficacious in terms of improving LUTS. 'Although the study demonstrated silodosin's superiority to placebo and non-inferiority to tamsulosin an adequately powered study is needed to determine whether silodosin can be shown to be clinically significantly superior to tamsulosin. Further research is required to see if non-responders to tamsulosin respond to silodosin and whether the long-term effectiveness of silodosin is better than that of tamsulosin. There is a fair way to go before silodosin has an established role in the management of LUTS caused by BPH.'
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22 Feb 2011
The empirical use of antibiotics for asymptomatic patients with raised PSA levels confers no benefit and should be discouraged, the authors of a study in the BJUI conclude. The trial aimed to compare the outcomes for patients who presented with borderline PSA who either had a repeat PSA after 45 days, or who received levofloxacin 500 mg daily for 30 days followed by a repeat PSA after the same interval. ' The practice of prescribing antibiotics to patients in this situation has been used to a degree by UK urologists. This study is by no means definitive, but makes it clear that the evidence for this practice is far from conclusive. For GPs the message must be that this is not a technique we should implement ourselves before referring for a urological opinion. There is clear value in repeating the PSA of a patient with a borderline result, but prescribing of antibiotics is not as yet an established management practice.'
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20 Dec 2010
A study from the University of Nottingham suggests that patients with an index finger longer than their ring finger have approximately two-thirds the risk of prostate cancer of those with equal finger lengths or longer ring fingers. The hypothesis is that the ratio of 2nd and 4th digit (index and ring fingers, 2D and 4D) length is fixed in utero and is altered by exposure to sex hormones at that time. The 2D:4D ratio is negatively correlated with testosterone exposure and positively related to oestrogen concentrations. This ratio may therefore act as a proxy indicator for prenatal testosterone levels. 'The study suggests that patients with an index finger longer than their ring finger have approximately two-thirds the risk of prostate cancer of those with equal finger lengths or longer ring fingers. Clearly, before you start studying your right hand, or that of your partner/father/friends etc, it should be remembered that this study has many limitations. It is a relatively small case-control study, relying on subjective self-collected data.'However, the findings are consistent with those of a paper in the British Journal of Urology,1 where those with a lower digit ratio (i.e. index finger shorter than ring finger) had higher mean PSA levels, higher risk of prostate biopsy and subsequent diagnosis of prostate cancer.
20 Dec 2010
Statin usage may defer the development of lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE) by up to seven years. The Olmsted County study, a huge cohort study that has been running in Minnesota for many years, has produced several important urological papers. The Olmsted County database was used to carry out a retrospective study of almost 2,500 men, aged 40-79 years, from 1990 to 2007. 'This study has significant flaws, most notably that it is a retrospective cohort study rather than a randomised controlled trial. Furthermore, the Olmsted County population is a largely affluent Caucasian community, and therefore it is unclear as to whether these results would apply across other ethnic and socio-economic groups. However, the results are interesting at a time of ever increasing statin prescription. There is a potential for vast public health benefit if the findings of this study were reproduced across our at-risk population.'
24 Nov 2010
For patients with non-visible haematuria, the probability of missing malignant disease with a guideline-based clinic protocol is less than 1% up to the age of 90. However, for visible haematuria the risk increases with age, and is greater than 4% by 70. This paper in the BJU follows up patients referred to the Plymouth haematuria clinic between 1998 and 2003. A total of 4,020 patients took part in the original study. All patients had a plain x-ray, renal tract ultrasound and flexible cystoscopy as part of their original investigation. Intravenous urography was also performed after abnormal first-line investigation or in patients with persistent haematuria at presentation where no abnormality had been detected. 'We must never assume that the haematuria clinic protocol for investigation is infallible, and for patients with visible haematuria it is important to repeat investigation if further episodes occur (or at least seek specialist advice). However, the study does not support the unselected use of additional upper tract imaging in all haematuria patients, but instead suggests that this should be targeted towards those over 50 with visible haematuria.'
21 Sep 2010
Absence of symptoms and negative dipstick results do not rule out infection in patients with suspected UTI, a primary care study has found. The researchers aimed to identify which clinical features and dipstick variables independently predict laboratory diagnosis of UTI, and to validate clinical decision rules based on these independent predictors. A total of 434 women with suspected UTI were recruited to the study from practices in the south of England. They were asked to rate the presence of symptoms and their severity. A midstream urine specimen was examined for cloudiness to the naked eye, and offensive odour, before urine dipstick testing was carried out. 'GPs need to be aware that in a patient with suspected UTI, absence of classic symptoms or negative dipstick results do not reliably rule out the presence of infection. Thus, alternative strategies are required for these patients, whether arranging clinical review if symptoms persist or the use of delayed prescriptions.'
21 Sep 2010
Antimicrobial sensitivity results from a previous infection are a useful guide to empirical treatment of re-infection, a study from Ireland has shown. The researchers aimed to analyse sensitivity patterns to identify predictive values of previous E. coli isolates for the treatment of re-infections in clinical practice. 'Resistance to nitrofurantoin was low in this sample, and even when detected was found to decay relatively quickly. This study would suggest that nitrofurantoin is now, therefore, a better choice of empirical antibiotic for UTI unless previous MSU results have suggested trimethoprim susceptibility (within the previous year). This is consistent with the latest guidelines from the Health Protection Agency (HPA), recommending the use of nitrofurantoin as first-line empirical antibiotic in UTI.'
22 Jul 2010
A total of 200 patients attending a haematuria clinic in Quebec, Canada were studied. These patients were considered to be low risk for urothelial cancer as they were non-smokers, with no significant occupational risk factors, history of previous malignancies or radiotherapy or cyclophosphamide exposure. Approximately 15% of patients with atypical cytology were found to have tumours. When atypical cytology was analysed as a positive result, the sensitivity, specificity, positive predictive value and negative predictive value of the test were 50%, 90%, 17% and 98% respectively. 'The use of urine cytology in non-visible haematuria is currently recommended by the American Urological Association guidelines, but the British Association of Urological Surgeons/Renal Association guidelines in the UK do not recommend the routine use of cytology. While this study is small and can only be of limited use in determining the correct management strategy for this condition, it would appear to support the British guidelines. GPs should therefore observe these guidelines, with initial investigation in primary care of MSU to exclude infection plus measurement of renal function, albumin:creatinine ratio and blood pressure, followed by referral to secondary care for further investigation.'
21 Jul 2010
The risk of prostate cancer increases with the number of family members with the disease, particularly brothers, and with younger age at diagnosis, a nationwide study has shown. The national Swedish family cancer database was used to estimate age-specific familial risks of being diagnosed with prostate cancer according to the number and type of affected first-degree relatives and according to paternal and fraternal age at diagnosis. The registry includes records of >11.8 million individuals and their cancers over nearly 50 years. The authors also calculated the risk of dying from prostate cancer according to family history. This is the largest family study published with more than 26,000 prostate cancer cases, of which 5,600 were familial. 'The take home message... is that the risk of prostate cancer increases with the number of affected first-degree family members, particularly brothers, and with younger age at diagnosis. Therefore, patients who fall into higher-risk groups can be identified.'
23 Jun 2010
More men are receiving conservative management for low-grade prostate cancer, a British study has found. The authors used a longitudinal observational database, the British Association of Urological Surgeons Cancer Registry, to investigate patterns of care for low-risk, localised prostate cancer from 2000 to 2006. The database contains data from approximately 150 institutions and 400 urologists throughout the UK. 'This trend towards increasing conservative management of low-risk disease is in marked contrast to practice in the United States. If the findings of the study represent an accurate picture of patterns of care across the UK, it would indicate a significant shift in clinical practice.'
22 Jun 2010
Anxiety and distress levels do not change significantly during active surveillance for low-risk prostate cancer, the findings of a small Dutch study suggest.These results are useful to clinicians involved in helping patients in this complex decision making process. The impact of perceived physician involvement in decision making is important and emphasises the need for greater patient involvement. As well as informative literature and interactive technology, prostate cancer specialist nurses can also play a key role. These nurses have been shown to have a hugely beneficial role in helping patients arrive at a management decision.
19 May 2010
'For GPs it is also useful to know, that given the common co-existence of significant depression in cancer patients, treatment with an SSRI may significantly improve hot flushes for prostate cancer patients. Initiation of the more effective hormonal treatments will, however, most likely be carried out by uro-oncologists rather than in a primary care setting.'
18 May 2010
'REDUCE is an important study, but it must be interpreted with caution. While it shows interesting results in terms of overall reduction of prostate cancer cases, the story is complex and there is clearly more work to be done in establishing the exact role of 5 alpha-reductase inhibitors in reducing the risk of prostate cancer.'
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