Following the United States Preventative Services Task Force (USPSTF) recommendation against PSA screening in 2012, a significant amount of research has gone into ways to decrease overdiagnosis and overtreatment of prostate cancer. Through this emerged more specialized protocols for active surveillance of low-risk prostate cancer and better understanding into the utility of prostate MRI. Great interest has been generated with the ability of a prostate MRI to identify prostate tumors that can be targeted for prostate biopsy.
Prostate MRI has been performed for years with the use of a 1.5 Tesla machine and would require an endorectal coil to fully evaluate the seminal vesicles. With the widespread adoption of 3.0 Tesla machines, the endorectal coil is no longer needed in most cases for improved anatomic delineation. The PI-RADs scoring system was developed to standardize the interpretation of prostate multiparametric MRI (mpMRI) given its rapidly growing progress in the field of prostate cancer management. The higher the score, the higher the chance the prostate lesion represents cancer.
The question then emerges: Can I obtain a prostate MRI if I have an elevated PSA and save myself from a prostate biopsy? Data looking at the use of MRI prior to an initial biopsy has had variable results. A recent study from BJUI evaluated 75 men who had a negative 3.0 Tesla mpMRI and underwent a standard 12-core prostate biopsy. They found that a negative prebiopsy mpMRI conferred an 82% chance for NOT having any type of prostate cancer and a 98% chance for NOT having Gleason ≥ 7. Additionally, 124 men in the Göteborg randomized screening trial assessed the use of pre-biopsy MRI with targeted prostate biopsy compared against traditional systematic prostate biopsy. They found that prostate MRI and targeted biopsy yielded improved cancer detection and found a PSA value of 3 being the best cutoff value to avoid over-detection of clinically insignificant cancer.
Data from the PROMIS trial was published earlier this year in The Lancet. Over 500 men with elevated PSA or an abnormal DRE participated and underwent an initial 1.5 Tesla mpMRI followed by standard transrectal ultrasound prostate biopsy. MRI demonstrated a higher sensitivity for detecting clinically significant prostate cancer (93% vs 48%, p<0.0001), but does have a low specificity and positive predictive value, meaning that it does not serve as a replacement to having a prostate biopsy done if the MRI is suspicious. In this study, it was determined that 27% of men could have safely avoided a prostate biopsy based on the mpMRI findings. Currently, only a few insurances are covering the MRI prior to prostate biopsy, with typical out-of-pocket costs approaching $3,000.
The utility for MRI-guided fusion biopsy has been established for men with a rising PSA despite already having a negative prostate biopsy. MRI findings of PI-RADS 4 or 5 are highly suspicious for malignancy and warrant a biopsy. In a Consensus Statement between the American Urologic Association (AUA) and the Society of Abdominal Radiology (SAR), the recommendation is for men with a prior negative prostate biopsy to undergo a high-quality prostate MRI prior to repeat biopsy. MRI-targeted biopsies are being found to be more effective for detecting prostate cancer in this patient population (11-54%) over standard repeat prostate biopsy.
What about men who have a negative or indeterminate prostate MRI (PI-RADs 1-2)? A study of 84 men still found aggressive prostate cancer (Gleason 7 or greater) in 10.3% of biopsy-naïve men, 16.7% of patients with a previous negative biopsy, and 13.3% of men on active surveillance. This data suggests that a negative prostate MRI does not put you in the clear; rather, you still will require close monitoring and surveillance.
Your doctors at Potomac Urology are proud to partner with Invivo to provide the UroNav MRI-fusion prostate biopsy services to the Northern Virginia, Southern Maryland and Washington D.C. region. Working in collaboration with radiologists and pathologists, we have established a protocol that delivers a more precise, highly accurate prostate biopsy without sacrificing patient comfort or effective results. If interested in this service, or to learn more, please schedule an appointment today by calling 703-680-2111. Together we will continue to make strides toward a greater future!
Recently published in the New England Journal of Medicine, the ProtecT trial is a prospective, randomized clinical trial assessing men aged 50 to 69 years of age assigned to either active surveillance, radical prostatectomy, or external beam radiation coupled with androgen deprivation therapy. The key finding recently publicized in the media was no difference among the three groups in overall survival or cancer-specific survival at the end of the 10-year study (Figure A). As seen in Figure B, those men under active surveillance were at a 2.5x increased risk for disease progression compared to the other 2 treatment groups.
Additionally, an important characteristic to keep in mind is assessing baseline study characteristics. In Table S2, over 75% of each treatment cohort was made up of men with Gleason 6 disease, therefore the study was mainly a comparison of low-risk men. It is a well-known fact that many men with Gleason 6 disease tend to act favorably, thus the success of treatment methods such as active surveillance. In a comparison of mortality, the true benefit for surgical or radiation effect would be seen in men with either intermediate or high-risk disease (Gleason 7 or greater). I believe the reason for the higher numbers of Gleason 6 diagnosed men in this study is a direct validation of population-based PSA screening. As these men are followed out to 10 years, I believe the true benefit for the treatment of these slowly progressing tumors won’t be seen until greater than 15 to 20 years later.â€‹
What is interesting is this study was well done with only 1% of patients lost to follow-up. Also interesting was the fact that almost 50% of patients on active surveillance opted for treatment intervention during the 10 year study period. Some of these were due to PSA increases and others due to anxiety, which must be balanced when discussing the risks and benefit with the patient.
While this represents a nice study assessing outcomes from the 3 most common treatment options for prostate cancer, I believe that carrying the study out 15 and even 20 years later will show a differentiation among treatment groups. Also, I’d be more interested in seeing more comparisons for men with intermediate or high-risk prostate cancer, as these are the men at most risk for metastasis and death.
In both urology and primary care practices, bothersome lower urinary tract symptoms are one of the most frequent causes for patient visits or calls. As physicians, we bear a responsibility to both treat our patients as well as guard against the over-prescription of antibiotics. There has been an increasing prevalence of resistant urinary tract infections (UTI) and here are some helpful hints.
As a urologist fellowship-trained in female urology, I see many patients for recurrent UTIs. So, how do I handle these calls? Here are my guidelines based on evidence-based practices as well as personal experience:
What makes the diagnosis of a recurrent UTI?
More than three culture-proven UTI’s in a consecutive 12 month period
Do all patients with recurrent UTI’s require a workup?
In short, the answer is NO. However, you need a culture history before making this decision.
We recommend an evaluation/referral for the following groups:
A. Recurrent UTI's with the same organism
B. Evidence for bacterial persistence—same bacteria re-cultured within two weeks of successful treatment
C. Prior urinary tract surgery
D. History of kidney stones
E. Abnormal urinary symptoms in the absence of infection
F. Recurrent febrile UTI's
G. Evidence of enterovesical fistula such as pneumaturia
H. Patients with complications due to antibiotic use
How do I treat patients with recurrent UTI's?
1. Post-coital antibiotics: Prescribe Nitrofurantoin 100mg to be taken immediately after or before intercourse (within one hour)
2. Self-start antibiotic therapy: Used in responsible patients only. No more than three refills per year. Determine which antibiotic based on most recent cultures.
3. Daily suppressive antibiotics: Options include: Nitrofurantoin 50mg taken daily Monurol (Fosfomycin) — 1 packet taken once a week Keflex 250mg daily (used primarily in first trimester of pregnancy) Fluoroquinolones: not recommended Sulfa agents: not recommended.
- Nitrofurantoin 50mg taken daily
- Monurol (Fosfomycin) — 1 packet taken once a week
- Keflex 250mg daily (used primarily in first trimester of pregnancy)
- Fluoroquinolones: not recommended
- Sulfa agents: not recommended
Are there any NON-antibiotic treatments that are evidence-based?
1. Hiprex (Methenamine Hippurate): 500mg taken twice daily, used as a urinary sterilizing agent. Converted to mild form of formaldehyde and ammonia in urine. Best used in combination with 1000mg daily vitamin C as an acidifying agent for the urine.
2. Lactobacillus Vaginal Suppositories: These are the only probiotic supplements which have been shown in studies to decrease risk of UTI. These are available on Amazon under the Purfem brand name. Difficult to obtain in local pharmacies.
3. Topical Vaginal Estrogen: These are used in such small quantities that effect on circulating estrogen is thought to be minimal. These restore normal vaginal pH as a barrier against infection.
What has been shown NOT to work?
1. D-Mannose: The internet is rife with first person reports of efficacy of D-mannose as an inhibitor to bacterial adherence, and many homeopathic remedies for UTI’s contain this. There is no reproducible data that shows efficacy.
2. Cranberry Juice/Supplements: For many years use of these supplements was considered well supported in our literature. However, recent Cochran review found that the prevailing evidence is not strong enough to recommend use. This may be due in part to variability in quality and dosage of active ingredients in an unregulated supplement industry.
3. Cider vinegar: “The miracle drug of 2015.” We have seen numerous patients who have started drinking this on a daily basis. We can find no evidence to support its use, unless the patient loves the taste of it.…in which case carry on.
What has NOT been studied?
1. Wiping front to back: While this makes all the sense in the world—there are no studies that look at differences in number of UTI’s in women who wipe back to front instead of front to back.
2. Urinating after intercourse: Again, this makes sense—but has never been studied.
3. Douche or use of tampons: No studies, though it makes sense that these activities can increase risk
4. Increasing fluid intake: As surgeons, we heard the phrase “Dilution is the solution to pollution” quite frequently—and have applied this idea to UTI prevention…. but have never studied it
Want to know more?
Here is a list of references that contain additional information to the summary listed above:
1. Foxman B, Barlow R, D’Arcy H, et al. Urinary tract infection: self-reported incidence and associated costs. Ann Epidemiol 2000;10:509-15.
2. Foxman B. Recurring urinary tract infection: incidence and risk factors. Am J Public Health 1990;80:331-3.
3. Epp A, Larochelle A, Lovatsis D, et al. Recurrent urinary tract infection. J Obstet Gynaecol Can 2010;32:1082-101.
4. Grabe M, T.E. Bjerklund-Johansen, H. Botto, et al. European Association of Urology: Guidelines on Urological Infections; 2010.
5. Segal AJ, Amis ES Jr, Bigongiari LR, et al. Recurrent lower urinary tract infections in women. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215:671-6.
6. ACOG Practice Bulletin No. 91: Treatment of urinary tract infections in nonpregnant women. Obstet Gynecol 2008;111:785-94.
7. Echols RM, Tosiello RL, Haverstock DC, et al. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Clin Infect Dis 1999;29:113-9.
8. Hooton TM. Recurrent urinary tract infection in women. Int J Antimicrob Agents 2001;17:259-68.
9. Hooton TM. Recurrent urinary tract infection in women. UpToDate. 2011. http://www.uptodate.com/ contents/recurrent-urinary-tract-infection-in-women. Accessed September 21, 2011.
10. Campbell MF, Wein AJ, Kavoussi LR. Campbell-Walsh Urology. 9th edition. Philadelphia: W.B. Saunders; 2007.
11. Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002;287:2701-10.
12. Giesen LG, Cousins G, Dimitrov BD, et al. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. BMC Fam Pract 2010;11:78.
13. Dielubanza EJ, Schaeffer AJ. Urinary tract infections in women. Med Clin North Am 2011;95:27-41. 14. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996;335:468-74.
15. Neal DE Jr. Complicated urinary tract infections. Urol Clin North Am 2008;35:13-22; v.
16. Raz R, Gennesin Y, Wasser J, et al. Recurrent urinary tract infections in postmenopausal women. Clin Infect Dis 2000;30:152-6.
17. Hooton TM, Stapleton AE, Roberts PL, et al. Perineal anatomy and urine-voiding characteristics of young women with and without recurrent urinary tract infections. Clin Infect Dis 1999;29:1600-1.
18. Nicolle LE. Uncomplicated urinary tract infection in adults including uncomplicated pyelonephritis. Urol Clin North Am 2008;35:1-12, v.
19. Lawrentschuk N, Ooi J, Pang A, et al. Cystoscopy in women with recurrent urinary tract infection. Int J Urol 2006;13:350-3.
20. Engel G, Schaeffer AJ, Grayhack JT, et al. The role of excretory urography and cystoscopy in the evaluation and management of women with recurrent urinary tract infection. J Urol 1980;123:190-1.
21. Fowler JE Jr, Pulaski ET. Excretory urography, cystography, and cystoscopy in the evaluation of women with urinary-tract infection: a prospective study. N Engl J Med 1981;304:462-5.
22. van Haarst EP, van Andel G, Heldeweg EA, et al. Evaluation of the diagnostic workup in young women referred for recurrent lower urinary tract infections. Urology 2001;57:1068-72.
23. Mogensen P, Hansen LK. Do intravenous urography and cystoscopy provide important information in otherwise healthy women with recurrent urinary tract infection? Br J Urol 1983;55:261-3.
24. Nickel JC, Wilson J, Morales A, et al. Value of urologic investigation in a targeted group of women with recurrent urinary tract infections. Can J Surg 1991;34:591-4.
25. Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Can Urol Assoc J 2009;3:77-80.
26. Aslaksen A, Baerheim A, Hunskaar S, et al. Intravenous urography versus ultrasonography in evaluation of women with recurrent urinary tract infection. Scand J Prim Health Care 1990;8:85-9.
27. Spencer J, Lindsell D, Mastorakou I. Ultrasonography compared with intravenous urography in investigation of urinary tract infection in adults. BMJ 1990;301:221-4.
28. Andrews SJ, Brooks PT, Hanbury DC, et al. Ultrasonography and abdominal radiography versus intravenous urography in investigation of urinary tract infection in men: prospective incident cohort study. BMJ 2002;324:454-6.
29. McNicholas MM, Griffin JF, Cantwell DF. Ultrasound of the pelvis and renal tract combined with a plain film of abdomen in young women with urinary tract infection: can it replace intravenous urography? A prospective study. Br J Radiol 1991;64:221-4.
30. Lewis-Jones HG, Lamb GH, Hughes PL. Can ultrasound replace the intravenous urogram in preliminary investigation of renal tract disease? A prospective study. Br J Radiol 1989;62:977-80.
31. Jagjivan B, Moore DJ, Naik DR. Relative merits of ultrasound and intravenous urography in the investigation of the urinary tract. Br J Surg 1988;75:246-8.
32. Kodner CM, Thomas Gupton EK. Recurrent urinary tract infections in women: diagnosis and management. Am Fam Physician 2010;82:638-43.
33. Scholes D, Hooton TM, Roberts PL, et al. Risk factors for recurrent urinary tract infection in young women. J Infect Dis 2000;182:1177-82.
34. Fihn SD, Boyko EJ, Chen CL, et al. Use of spermicide-coated condoms and other risk factors for urinary tract infection caused by Staphylococcus saprophyticus. Arch Intern Med 1998;158:281-7.
35. Handley MA, Reingold AL, Shiboski S, et al. Incidence of acute urinary tract infection in young women and use of male condoms with and without nonoxynol-9 spermi
36. Sen A. Recurrent cystitis in nonpregnant women. Clin Evid (Online) 2008;pii: 0801.
37. Barrons R, Tassone D. Use of Lactobacillus probiotics for bacterial genitourinary infections in women: a review. Clin Ther 2008;30:453-68.
38. Abad CL, Safdar N. The role of lactobacillus probiotics in the treatment or prevention of urogenital infections--a systematic review. J Chemother 2009;21:243-52.
39. Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2008:CD001321.
40. Stothers L. A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women. Can J Urol 2002;9:1558-62.
41. Kontiokari T, Sundqvist K, Nuutinen M, et al. Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ 2001;322:1571.
42. Barbosa-Cesnik C, Brown MB, Buxton M, et al. Cranberry juice fails to prevent recurrent urinary tract infection: results from a randomized placebo-controlled trial. Clin Infect Dis 2011;52:23-30.
43. Albert X, Huertas I, Pereiró II, et al. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004:CD001209.
4. Cetti RJ, Venn S, Woodhouse CR. The risks of long-term nitrofurantoin prophylaxis in patients with recurrent urinary tract infection: a recent medico-legal case. BJU Int 2009;103:567-9.
45. Stamm WE, Counts GW, Wagner KF, et al. Antimicrobial prophylaxis of recurrent urinary tract infections: a double-blind, placebo-controlled trial. Ann Intern Med 1980;92:770-5.
46. Pfau A, Sacks T, Engelstein D. Recurrent urinary tract infections in premenopausal women: prophylaxis based on an understanding of the pathogenesis. J Urol 1983;129:1153-7.
47. Schaeffer AJ, Stuppy BA. Efficacy and safety of selfstart therapy in women with recurrent urinary tract
infections. J Urol. 1999;161:207-211.
48. Gupta K, Hooton TM, Roberts PL, Stamm WE.Patient-initiated treatment of uncomplicated recurrent
urinary tract infections in young women. AnnIntern Med. 2001;135:9-16.
49. Gupta K, Hooton TM, Naber KG, et al. Internationalclinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women:a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiologyand Infectious Diseases. Clin Infect Dis. 2011;52:
50. Stapleton A, Latham RH, Johnson C, StammWE. Postcoital antimicrobial prophylaxis for recurrent
urinary tract infection. A randomized,double-blind, placebo-controlled trial. JAMA.
51. Melekos MD, Asbach HW, Gerharz E, et al. Postintercourseversus daily ciprofloxacin prophylaxis for
recurrent urinary tract infections in premenopausalwomen. J Urol. 1997;157:935-939.
52. Albert X, Huertas I, PereiroÅL II, et al. Antibioticsfor preventing recurrent urinary tract infection in
non-pregnant women. Cochrane Database Syst Rev.004;(3):CD001209.
53. Guibert J, Humbert G, Meyrier A, et al. Antibiopreventionof recurrent cystitis. A randomized doubleblindcomparative trial of 2 dosages of pefloxacin [inFrench]. Presse Med. 1995;24:213-216.
54. Cetti RJ, Venn S, Woodhouse CR. The risks of longterm nitrofurantoin prophylaxis in patients with recurrenturinary tract infection: a recent medico-legalcase. BJU Int. 2009;103:567-569.
55. Schmidt DR, Sobota AE. An examination of theanti-adherence activity of cranberry juice on urinary
and nonurinary bacterial isolates. Microbios. 1988;55:173-181.
56. Lavigne JP, Bourg G, Combescure C, et al. In-vitroand in-vivo evidence of dose-dependent decrease
of uropathogenic Escherichia coli virulence afterconsumption of commercial Vaccinium macrocarpon
(cranberry) capsules. Clin Microbiol Infect.2008;14:350-355.
57. Howell AB, Botto H, Combescure C, et al. Dosageeffect on uropathogenic Escherichia coli anti-adhesionactivity in urine following consumption of cranberrypowder standardized for proanthocyanidin content:a multicentric randomized double blind study. BMInfect Dis. 2010;10:94.
In addition to greatly improving our overall quality of life and the ability to perform everyday tasks with more efficiency, modern technology has lead to extraordinary developments in medical treatment and surgical techniques. Many procedures that once required traditional open surgery and extended hospital stays with longer recovery periods can now be performed with minimally invasive procedures (laparoscopic, and robotic-assisted surgery).
Minimally Invasive Urology Surgery in Alexandria and Woodbridge, VA
With smaller incisions using instrumentation that allows for less blood loss, less risk of infections, and less risk of trauma to surrounding tissue, the urologists at Potomac Urology in Alexandria and Woodbridge, VA performs many diagnostic and treatment procedures with greater accuracy and fewer side effects.
Some of the procedures that are performed with minimally invasive laparoscopic or robotic surgery include:
- Prostate removal (prostatectomy)
- Full or partial kidney removal (nephrectomy)
- Bladder removal (cystectomy)
- Pelvic organ prolapse repair (sacrocolpopexy)
- Kidney blockage repair (pyeloplasty)
- Removal of adrenal gland (adrenalectomy)
Some of the many benefits of less invasive urology surgery include:
- Shorter recovery period and faster healing
- Minimal disruption to daily routines and quality of life
- Less risk of infections and side effects associated with more invasive open surgery
- Less time off work
- Shorter time in the hospital
- Prostate biopsies
Find a Urologist in Alexandria and Woodbridge, VA
Many people put off necessary diagnostic procedures and treatment for fear of surgery or concerns over how an extended recovery period might affect personal and professional obligations. Minimally invasive and outpatient surgery has become an option for more and more procedures, helping to drastically reduce recovery time and side effects. For more information on how it works and whether it is an option for you, contact Potomac Urology by calling (703) 680-2111 to schedule an appointment today.
For most people, a cancer diagnosis is a scary thing. According to the American Cancer Society, doctors diagnose about 181,000 new cases of prostate cancer per year in the United States. However, if caught and treated early, prostate cancer has an exceptionally high cure rate for patients who begin treatment in the early stages. Learn more about the testing and treatment of prostate cancer with help from your Alexandria, VA urologists at Potomac Urology.
What are the symptoms of prostate cancer?
While the majority of people do not experience any symptoms of prostate cancer, some tell-tale signs of advanced prostate cancer may include:
- difficulty urination
- increased frequency of urination
- painful urination
- blood in urine
- difficulty maintaining an erection
- blood in the semen
- pain in the hips, lower back or upper legs
Early detection of prostate cancer increases the chance of successful treatment. If you experience one or more of these symptoms, you should schedule an appointment with your Alexandria doctor as soon as possible. Since these symptoms may also be related to other medical conditions, your doctor uses special screening to determine the presence of prostate cancer.
How does a prostate cancer screening work?
Your doctor may perform a prostate cancer screening one of two ways. A digital rectal exam, or DRE, involves inserting a lubricated finger into the rectum to manually feel for lumps or irregularities and determine if the prostate is of a normal size. A prostate-specific antigen, or PSA, test measures the presence of PSA in the blood using a blood test. The idea is that the more elevated the PSA levels in the blood, the higher the chance of a prostate problem. Your doctor can help you determine which test is best for you. Recently, there have also been some newer blood and urine tests that have emerged as promising tests to help improve the accuracy of PSA testing.
What are the treatments for prostate cancer?
Prostate cancer grows very slowly, so some cases may not require immediate treatment. If the patient has more severe medical conditions or is very old, their doctor may suggest simply monitoring the disease. If the cancer is contained within the prostate gland, your doctor may recommend surgery to remove the gland and any affected tissue altogether. Radiation therapy, hormone therapy, and, in some cases, chemotherapy also treat prostate cancer. With many options available, you can work with your urologist to determine which treatment is best for you, your lifestyle and your condition.
For more information on finding and treating prostate cancer, please contact your urologist at Potomac Urology in Alexandria, VA. Call (703) 680-2111 to speak with an associate about scheduling your appointment for an examination today!
This website includes materials that are protected by copyright, or other proprietary rights. Transmission or reproduction of protected items beyond that allowed by fair use, as defined in the copyright laws, requires the written permission of the copyright owners.