COMMON DISEASES IN THE MALE
Educational Objectives
The goal of this program is to improve the management of benign prostatic hyperplasia (BPH), urinary incontinence in
men, and prepubertal testis tumors. After hearing and assimilating this program, the clinician will be better able to:
 | 1. Use α-blockers and other drugs in the treatment of BPH.
|
| 2. Administer minimally invasive treatments for BPH, such as transurethral microwave therapy, transurethral needle
ablation, prostatic stents, and lasers.
|
| 3. Treat stress urinary incontinence using the artificial urinary sphincter or the male urethral sling.
|
| 4. Diagnose prepubertal testis tumors using ultrasonography, tumor markers, and frozen sections.
|
| 5. Describe the pathophysiology of the most common prepubertal testis tumors and their management with testis-sparing
surgery.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Badlani
is a consultant for American Medical Systems, is on the Speakers’ Bureau for Pfizer, and is a study consultant for Schering
Plough. Dr. Nehra is a consultant for Pfizer and GlaxoSmithKline. Dr. Rushton and the planning committee reported nothing
to disclose.
Acknowledgements
Drs. Badlani and Nehra were recorded at Urology Today: 1st Annual Update, held November 8-11, 2007, in Blowing
Rock, NC, and cosponsored by Wake Forest University Health Sciences, Winston-Salem, NC, and Mayo Clinic,
Rochester MN. Dr. Rushton gave his scientific presentation at Advances in Urology 2007, held November 30 to December
1, 2007, in Atlanta, GA, and sponsored by Emory University School of Medicine, Emory University Hospital,
Atlanta Veterans Affairs Medical Center, and Grady Memorial Hospital. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
BPH: Minimally Invasive Therapy
Gopal H. Badlani, MD, Professor and Vice Chair, Department of Urology, Wake Forest University and Baptist Medical
Center, Winston-Salem, NC
| Introduction: data from World Health Organization (WHO); drugs—most minimally invasive therapy; latest
guidelines—from European Urology; similar to American Urological Association (AUA) guidelines but more recent
|
| Benign prostatic hyperplasia (BPH): progressive disease; age plays role; prostate-specific antigen (PSA) now used for
BPH management and in choice of preventive therapy; volume of prostate makes difference; PSA tertiles—presenting PSA
>1.5 ng/mL and prostate volume >30 mL predict progression and need for intervention; presenting PSA <1.5, symptom score
<7, and prostate volume <30 mL unlikely to require treatment; risk for needing treatment or surgery progresses from baseline,
depending on symptom complex; nocturia most bothersome symptom; medical algorithm depends on symptom score and
level of bother
|
Drug Therapy
| α-blockers: low-volume prostate and moderate to severe bother—rapid (within 1-2 wk) response; discontinue if no response
by 6 wk; work on long-term basis; combination therapy (α-blocker plus 5-α-reductase inhibitor [ARI]) used to
prevent progression; anticholinergic agent used with α-blocker for overactivity (eg, frequency, urgency) symptoms and
sexual dysfunction; no fear of urinary retention with anticholinergic agents, but patient must not have large initial
postvoid residual or flow rate <8 mL/sec; large-volume prostate and moderate to severe bother—ARI useful alone for
prevention or with α-blocker; cost relevant factor in combination therapy; speaker finds ARIs have no clinical efficacy
when used alone
|
Minimally Invasive Therapy (MIT)
| Indications: for those who fail drug therapy, refuse long-term drug therapy, or have intolerable side effects; frequency of
use exceeds that of transurethral resection of prostate (TURP)
|
| Transurethral microwave thermotherapy (TUMT): low-energy—barely raises temperature beyond 2 mm away
from urethra; high-energy—mimics destruction of tissue by TURP; 5-yr data from randomized trials—show TURP better
at improving flow, but high-energy therapy approximately equal to TURP for symptom relief; retreatment rate ≈25%
over 5 yr for heat-based therapy (based on first-generation machines; newer machines better but no 5-yr data);
morbidity—depends on energy used; with high-energy machines, rate of urinary retention higher and duration of catheterization
longer; also includes dysuria; new temporary stent expected to be helpful; method—“dial-up” therapy, ie, raise
energy level to patient’s tolerance and remain with patient for duration of therapy (15-18 min); committee findings—low
morbidity; truly outpatient; done anesthesia-free or with local block; good clinical outcomes seem durable; indicated for
high-risk patients who require instrumental therapy
|
| Transurethral needle ablation (TUNA): not in AUA guidelines, due to lack of long-term data; second-generation
machines easier to use in office; symptom improvement equivalent to other methods (≈66% of patients do better); retreatment
rate ≈25%
|
| Alcohol injection: not in use because of major side effects during trials in United Kingdom (UK); Food and Drug Administration
(FDA) placed hold on system; data show easy and safe to do in office, and outcomes similar to those with
other MITs
|
| Prostatic stents: immediate improvement in flow; patient selection important (no middle lobe gland <5 cm); use limited by
anatomic prerequisites; no level 1 evidence; UroLume stent—≤7-yr and 11-yr studies show improvement in symptom score
and flow rate maintained; explantation of concern; in trial, majority of explantations occurred in first year because of use of
rolling membrane catheter for deployment of stent; with deployment tool now in use, stent rarely moves; stricture application
stable, but explantation continues in BPH application
|
| Lasers: holmium laser—difficult to use, but efficacy matches that of suprapubic prostatectomy; level 1 evidence available,
but learning curve and morcellation technique difficult; randomized controlled trials (RCTs) show good outcomes;
green light (potassium titanyl phosphate [KTP]) laser—1-yr RCT; 5-yr data on 11 patients; flow rates, symptom scores,
and postvoid residual match those of TURP; duration of catheterization less than for TURP; decrease in international
prostate symptom score (IPSS) somewhat better than with TURP; Qmax (mL/sec) better; photoselective vaporization of
prostate (PVP) with KTP laser takes longer than with TURP, and most urologists do not spend required time, so undertreatment
and recurrence affecting outcomes; study of 27 patients showed associated irritative symptoms, voiding dysfunction,
and dysuria (attributed to incomplete vaporization)
|
| Transurethral resection: recent advancements—use of generator; improved loops; bipolar electrosurgical resection in
saline environment, eg, PK technology (proprietary; Gyrus), reduces catheterization time (≈48 hr) and length of stay;
retreatment—RCTs show ≈13% of patients need retreatment, either re-resection or repair of stricture or bladder neck
contracture; outcomes data (Cochrane Library)—pooled data on ≈17000 patients; symptom scores for various techniques
closely matched, although ablative therapies (eg, TURP) give maximum improvement, compared to MITs (eg,
TUMT); quality of life closely matched, but maximal with ablative therapies; flow rate maximal with ablative therapies,
lowest with MIT; postvoid residual better with ablative therapy
|
Urinary Incontinence: AUS vs Sling
Ajay Nehra, MD, Professor of Urology, Mayo Clinic College of Medicine, Rochester, MN
| Etiology of urinary incontinence (UI) in men: caused by sphincteric dysfunction, predominantly from radical retropubic
prostatectomy (RRP; ≤10%), but some from TURP and some of neuropathic etiology; urodynamic evidence that
bladder dysfunction occurs in 48% to 60% of patients after RRP
|
| Slings: used mostly in women; possibly beneficial in men; may compress urethra; avoid suprapubic incision; could prevent
long-term urethral atrophy
|
| Treatment of stress UI in men: for ≤12 mo after surgery, observation, Kegel exercises, and pharmacologic approaches;
speaker prefers artificial urinary sphincter (AUS) for patients with moderate to severe stress UI; mean age at diagnosis of
prostate cancer ≈57 yr; using even one pad daily may be distressing to patients; preoperative evaluation—urodynamic studies;
classic leak point pressures; cystoscopic evaluation to rule out bladder neck contractures and urethral strictures; do not
place sling in patient with bladder neck contracture or stricture; treat or at least stabilize, then wait 12 to 16 wk or longer
|
| Artificial urinary sphincter: multicomponent with bulbourethral cuff; various reservoir pressures available, but
speaker usually uses 61 to 70 cm H2 O; to prevent urethral atrophy, use lower pressures (51-60 cm H2 O) in patients
who have had radiation therapy (urethral ischemia usually present); mechanical aspects—control pump implanted in
scrotum; button placed anterolaterally so patients with limited dexterity can use; prerequisites—sterile urine; bladder
capacity ≥200 mL; low urinary residual; incontinence for ≈1 yr; contraindications—chronic urinary tract infections
(UTIs); irreversible UT obstruction; low-volume detrusor hyperreflexia; unstable urethral strictures and/or urethral diverticulum
at potential cuff site
|
| Successful placement: dedicated surgical team; patient must use preoperative scrub (Hibiclens) from just below umbilicus to
mid thigh for 5 days before surgery (minimizes infections; in speaker’s team’s experience, combined infection rate for insertion
of penile prostheses and AUS 0.02%); severely limited traffic in operating room (OR); surgical technique—
patient in lithotomy position; dissect to level of bulbourethral segment; mobilize spongiosum away from tunica albuginea;
create 2-cm-wide plane around urethra to accommodate cuff; place cuff so tubing exits anterolaterally; pump in deactivated
state, with reservoir in prevesical space (separate incision in inguinal area); pump activated in 6 to 8 wk
|
| Results to date: 58% day cases; long-term cost same as for bulking agents; in literature, erosion rates 5%, infection rates
3%, mechanical failure rates ≤15%; ≈50% of patients have same AUS at 10 yr; tandem cuff de novo not needed when
working at level of bulbourethral segment; if urethral atrophy develops, add second cuff with connector to first;
pearl—speaker has patients deactivate AUS at night; this allows urethral reperfusion and prevents urethral atrophy;
educate patients preoperatively about rationale for deactivation and reinforce this postoperatively
|
| Male sling: contraindications—low-volume detrusor hyperreflexia or instability with diminished compliance; unstable
strictures or contractures; AdVance device—helical device with needle tip optimized to avoid damage to structures; handle
oriented to allow generation of high force and maximum torque; polypropylene mesh optimized for optimal retention and
high short-term tissue retention and stability; broad center allows fixation to corpus spongiosum and support of bulbar urethra
and perineal body; reinforced mesh ends used for strength during tensioning; within device, 2 long-lasting sutures with
multiple knots heat-sealed to mesh edges to enhance stability; mechanism of action—placed via transobturator approach; relocates
proximal part of anterior urethra into pelvic outlet, producing circumferential coaptation; residual sphincter function
maximized; results—long-term published data show success rates of 90% to 96%; use sling in patients with mild or mild-
to-moderate incontinence; new AUS with conditional occlusion being tested (awaiting results of single-center study)
|
Prepubertal Testis Tumors: Testis-sparing Surgery
H. Gil Rushton Jr, MD, Professor of Urology and Pediatrics, George Washington University School of Medicine, and
Chief, Division of Pediatric Urology, Children’s National Medical Center, Washington, DC
| Introduction: prepubertal testis tumors 1% of pediatric solid tumors; different from adult testis tumors in incidence, histology,
and prognosis; incidence—in children, 0.5 to 2 tumors per 100,000 (probably overestimate); in adults, 2.1 to 4 per
100,000
|
| Histology: mixed in >60% of adult testis tumors, but in <1% of childhood tumors (almost always pure histologic types); in
adults, >95% of tumors germ cell, (only 60% to 75% in children); some germ cell tumors common in adults never seen in
children, eg, seminoma, embryonal carcinoma, choriocarcinoma, teratocarcinoma; greater percentage of childhood tumors
benign, and malignant tumors in children less likely to metastasize; American Academy of Pediatrics (AAP) registry shows
yolk sac tumor most frequent, but several institutions report testis teratoma most common; speaker’s study—multi-institutional;
goal to establish true prevalence of histologic types; 98 boys <12 yr of age; culled >25 yr of pathology records from
institutions; found 74% of childhood testis tumors benign; teratoma most common (48%), and only 15% yolk sac tumors
|
| Evaluation of patients: history and physical examination; ultrasonography (US) helps confirm presence of mass and allows
accurate differentiation between intra- and extratesticular tumors; US also provides hints as to type of tumor, eg,
presence of cysts or calcification strongly suggests teratoma; tumor markers—yolk sac tumor only type in prepubertal
boys that produces α-fetoprotein (AFP; highly sensitive marker); AFP physiologically elevated in neonates (produced by
liver), so elevated AFP in first 6 mo of life not necessarily indication of yolk sac tumor; no role for preoperative human
chorionic gonadotropin (HCG) levels because HCG produced by choriocarcinoma (never seen in prepubertal boys); frozen
sections—during surgery; key component in testis-sparing approach; computed tomography (CT)—postoperative
abdominal and chest, depending on pathology found in surgery
|
| Yolk sac tumors: usually occur before 2 yr of age; most malignant of prepubertal testis tumors, but metastasis and death
relatively uncommon (<13% of patients); histology—Schiller-Duval body hallmark structure that produces AFP;
>90% of patients (possibly 100%) have elevated AFP, so serum AFP excellent preoperative predictor of tumor malignancy;
patterns of metastatic spread—in AAP registry, 33% of patients presented with metastatic disease, of which
27% retroperitoneal alone, 40% hematogenous alone, and 19% both; since retroperitoneal spread not predominant
mode of metastasis, routine retroperitoneal lymph node dissection (RPLND) not warranted in initial treatment of child
with yolk sac tumor
|
| Treatment: standard approach radical orchiectomy with weekly AFP measurement until levels normalize; most patients
have stage 1 disease, and close surveillance continued for minimum of 2 yr, including AFP and chest x-ray every 4 to
6 wk and CT every 3 mo; chemotherapy reserved for patients with metastatic disease or if AFP fails to normalize
within expected time; RPLND indicated when retroperitoneal disease does not respond to chemotherapy or AFP does
not normalize, and no evidence of other metastatic lesions on CT; UK Children’s Cancer Study Group (UKCCG)
data—73 boys <14 yr of age with testis tumors, of which 91% yolk sac; survivor rate 97%; 66% cured by orchiectomy
alone; 25 boys required chemotherapy, 2 of whom died, and 23 alive and well at long-term follow-up; AFP elevated in
all those in whom levels obtained; AFP levels identified all those not cured by surgery alone
|
| Teratoma of testis: most common primary testis tumor; prepubertal teratoma has benign clinical course; no reports of metastases
with mature or immature tumors; in past, radical orchiectomy routine approach; now, testis-sparing surgery being
performed by enucleation; cystic lesions in center of testis characteristic of teratoma (not seen with yolk sac tumors)
|
| Testis-sparing enucleation: approach through inguinal incision; when noncrushing tourniquet placed around cord and seminiferous
tubules pushed away, well-encapsulated tumor rolls out “like a marble”; if frozen sections confirm tumor
benign, testicle replaced and surgery completed; theoretic concerns—tumor seeding or spillage (rare in testis); incorrect
pathologic diagnosis (histologic features of testis tumors in children so distinct and so characteristic that problem
should not occur); sampling error (not issue because histology not mixed); multifocal disease (uncommon in children)
|
| Gonadal stromal tumors: Leydig cell tumors—patients present with precocious puberty, elevated testosterone, and low
gonadotropins associated with testicular mass; no cases of malignant unilateral tumors (always bilateral); in speaker’s series
of 5 boys, testis-sparing enucleation resulted in normal postoperative serum testosterone over 11 to 48 mo; Sertoli
cell and undifferentiated tumors—usually benign, but some malignancies reported in boys >5 yr of age, so orchiectomy
recommended; gonadoblastoma—rare in prepubertal children; seen most frequently in intersex patients with abnormal
gonads; usually found in streak gonad; some reports of malignancy; orchiectomy recommended
|
Suggested Reading
Agarwal PK et al: Testicular and paratesticular neoplasms in prepubertal males. J Urol 176:875, 2006; Armitage JN et al:
Epithelializing stent for benign prostatic hyperplasia: a systematic review of the literature. J Urol 177:1619, 2007; Grady RW:
Current management of prepubertal yolk sac tumors of the testis. Urol Clin North Am 27:503, 2000; Henderson CG et al:
Enucleation for prepubertal leydig cell tumor. J Urol 176:703, 2006; Henry GD et al: Perineal approach for artificial urinary
sphincter implantation appears to control male stress incontinence better than the transscrotal approach. J Urol 179:1475, 2008;
Kim SP et al: Long-term durability and functional outcomes among patients with artificial urinary sphincters: a 10-year retrospective
review from the University of Michigan. J Urol 179:1912, 2008; Leocádio DE et al: Office based transurethral needle
ablation of the prostate with analgesia and local anesthesia. J Urol 178:2052, 2007; Lourenco T et al: Minimally invasive
treatments for benign prostatic enlargement: systematic review of randomised controlled trials. BMJ 337:a1662, 2008; Nickel
JC: Inflammation and benign prostatic hyperplasia. Urol Clin North Am 35:109, 2008; Pohl HG et al: Prepubertal testis tumors:
actual prevalence rate of histological types. J Urol 172:2370, 2004; Ross JH et al: Clinical behavior and a contemporary
management algorithm for prepubertal testis tumors: a summary of the Prepubertal Testis Tumor Registry. J Urol 168:1675, 2002;
Seki N et al: Effects of photoselective vaporization of the prostate on urodynamics in patients with benign prostatic hyperplasia.
J Urol 180:1024, 2008; Shah DK et al: Experience with urethral stent explantation. J Urol 169:1398, 2003; Shore ND et al:
A temporary intraurethral prostatic stent relieves prostatic obstruction following transurethral microwave thermotherapy. J Urol
177:1040, 2007; Shukla AR et al: Experience with testis sparing surgery for testicular teratoma. J Urol 171:161, 2004; Tan A
et al: Meta-analysis of holmium laser enucleation versus transurethral resection of the prostate for symptomatic prostatic obstruction.
Br J Surg 94:1201, 2007; Thomas JC et al: Stromal testis tumors in children: a report from the prepubertal testis tumor
registry. J Urol 166:2338, 2001.
|
