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Re: Transobturator Versus Retropubic Synthetic Slings: Comparative Efficacy and Safety
1844
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
following factoids and opinions: 1) the prevalence of POP quantification stage 2 or greater prolapse in older women is reported as 37% to 50%; 2) the lifetime risk of undergoing surgery for POP or SUI is reported as about 11%; 3) the POP recurrence rate of traditional vaginal repair of anterior prolapse has been reported to be as high as 70%; 4) synthetic mesh usage in groin hernia repair, sacrocolpopexy and suburethral sling surgery is well established; the use of such mesh for vaginal prolapse repair results in improved anatomical outcomes and lower recurrence rates but no difference in subjective outcomes compared to traditional vaginal prolapse repairs. Alan J. Wein, M.D., Ph.D. (hon.)
Re: Transobturator Versus Retropubic Synthetic Slings: Comparative Efficacy and Safety M. A. Cerruto and W. Artibani Urology Clinic, Department of Surgery, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy Curr Opin Urol, 2011; 21: 275–280.
Purpose of Review: To review the reported effectiveness and safety of transobturator (TransOburator route, TOR) versus retropubic (retropubic tape) synthetic mid-urethral slings discussing the controversy existing on which of these procedures is best. Recent Findings: From August 2009 to January 2011 three meta-analyses of the pertinent topic were identified. They concluded that TOR was less favourable than the retropubic tape in objective cure rates without any significant difference in subjective cure rates. Moreover TOR showed a shorter operating time and less serious perioperative complications than retropubic tape, also when using a standardized complications grading system. The most recent RCTs confirmed these results. Summary: TOR showed similar short and mid-term subjective cure rates compared to retropubic tape; with a shorter operating time and a lower risk of perioperative complications. Subjective cure rates and patient satisfaction are crucial, thus, patientreport outcomes should be used as the primary outcome measure for all trials of incontinence treatments. The absence of standard methods for assessment of anti-incontinence procedures and the use of different methods to evaluate safety and effectiveness led to reporting of different rates of success and complications for the same procedure, making it difficult to compare data, to draw conclusions or make recommendations. Editorial Comment: The authors have combined 3 recent meta-analyses on this topic to derive the following data (transobturator vs retropubic results):1–3 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
objective cure rate— 84% vs 88% subjective cure rate— 83% in both groups operation length—20 vs 27 minutes length of hospital stay—no difference time to return to normal activity—no difference intraoperative blood loss— 48 vs 52 ml bladder perforation— 0.3% vs 5.5% major vascular injury—rare, no difference groin pain (after transobturator) vs suprapubic pain (after retropubic)—12% vs 1.7% postoperative voiding dysfunction— 4% vs 7% detrusor overactivity or de novo urgency with urgency incontinence—7% vs 6% quality of life improvement—no statistically significant difference
The authors close by stating, “The absence of standard methods for assessment of anti-incontinence procedures led to reporting of different rates of success for the same procedure. Moreover, because complete continence often seems not to be essential for patient satisfaction, scientists should tailor future randomized controlled trials on pa-
BENIGN PROSTATIC HYPERPLASIA
1845
tient-centered outcomes, taking into account patient expectations to achieve patient satisfaction.” Alan J. Wein, M.D., Ph.D. (hon.) 1. Novara G, Artibani W, Barber MD et al: Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence. Eur Urol 2010; 58: 218. 2. Ogah J, Cody JD and Rogerson L: Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009; 4: CD006375. 3. Latthe PM, Singh P, Foon R et al: Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials. BJU Int 2010; 106: 68.
Benign Prostatic Hyperplasia Re: Associations Between Variants in the Cyclooxygenase 2 Enzyme Gene (PTGS2) and Development of Benign Prostate Enlargement J. L. St. Sauver, M. M. Lieber, S. L. Slager, D. J. Jacobson, M. E. McGree and S. J. Jacobsen Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota BJU Int 2011; 108: 1610 –1615.
Objective: To determine if polymorphisms in the cyclooxygenase 2 (COX-2) enzyme gene (prostaglandin synthase 2; PTGS2) were associated with development of benign prostate enlargement (BPE), and whether associations were modified by use of nonsteroidal anti-inflammatory drugs (NSAIDs). Materials and Methods: Participants were men residing in Olmsted County, MN, who were between 40 and 79 years of age in 1990 (N ⫽ 356). Prostate volume was measured by transrectal ultrasound and men reported all the medications that they were taking at the time of the examination. Men were followed biennially for 16 years. Ten tagging single nucleotide polymorphisms (SNPs) in the PTGS2 gene were typed using the Illumina GoldenGate™ Assay. Associations between SNPs and development of BPE (volume ⬎30 mL) were assessed by Cox proportional hazards models. Models were also stratified by NSAID use. Results: We observed significant associations between four polymorphisms in the PTGS2 gene and development of BPE (all P ⬍0.05). These associations were not observed among men who used NSAIDs. Conclusion: Variants in the PTGS2 gene may increase the risk of prostate enlargement, but the increased risk may be minimized by use of NSAIDs. Editorial Comment: It is widely accepted that inflammation either directly or indirectly contributes to prostate growth. The relationship to lower urinary tract symptoms is less understood. One could argue that lower urinary tract symptoms are in fact secondary to prostatitis and that therapies designed to alleviate inflammation may alleviate symptoms. Specifically, agents such as 5alpha-reductase inhibitors may reduce the inflammatory component of prostate growth with a resulting decrease in prostate specific antigen and prostate volume. Our group previously reported using finasteride to treat prostatitis.1 Could anti-inflammatory processes be identified and associated proxies tested that may herald prostate growth? These authors performed some innovative work looking at these associations. They previously reported that daily NSAIDs may have a protective effect against the onset of moderate/severe urinary symptoms and flow rates.2 COX-2 is a mediator of inflammatory processes, and higher levels of COX-2 may contribute to higher levels of prostatic inflammation. Moreover, these increases may partly arise secondary to variations in the COX-2 gene, PTGS2. In this study the authors postulate that polymorphisms in this gene may be associated with prostate enlargement and that these associations can be modified by use of NSAIDs. By tagging single nucleotide polymorphisms, they observed
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
following factoids and opinions: 1) the prevalence of POP quantification stage 2 or greater prolapse in older women is reported as 37% to 50%; 2) the lifetime risk of undergoing surgery for POP or SUI is reported as about 11%; 3) the POP recurrence rate of traditional vaginal repair of anterior prolapse has been reported to be as high as 70%; 4) synthetic mesh usage in groin hernia repair, sacrocolpopexy and suburethral sling surgery is well established; the use of such mesh for vaginal prolapse repair results in improved anatomical outcomes and lower recurrence rates but no difference in subjective outcomes compared to traditional vaginal prolapse repairs. Alan J. Wein, M.D., Ph.D. (hon.)
Re: Transobturator Versus Retropubic Synthetic Slings: Comparative Efficacy and Safety M. A. Cerruto and W. Artibani Urology Clinic, Department of Surgery, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy Curr Opin Urol, 2011; 21: 275–280.
Purpose of Review: To review the reported effectiveness and safety of transobturator (TransOburator route, TOR) versus retropubic (retropubic tape) synthetic mid-urethral slings discussing the controversy existing on which of these procedures is best. Recent Findings: From August 2009 to January 2011 three meta-analyses of the pertinent topic were identified. They concluded that TOR was less favourable than the retropubic tape in objective cure rates without any significant difference in subjective cure rates. Moreover TOR showed a shorter operating time and less serious perioperative complications than retropubic tape, also when using a standardized complications grading system. The most recent RCTs confirmed these results. Summary: TOR showed similar short and mid-term subjective cure rates compared to retropubic tape; with a shorter operating time and a lower risk of perioperative complications. Subjective cure rates and patient satisfaction are crucial, thus, patientreport outcomes should be used as the primary outcome measure for all trials of incontinence treatments. The absence of standard methods for assessment of anti-incontinence procedures and the use of different methods to evaluate safety and effectiveness led to reporting of different rates of success and complications for the same procedure, making it difficult to compare data, to draw conclusions or make recommendations. Editorial Comment: The authors have combined 3 recent meta-analyses on this topic to derive the following data (transobturator vs retropubic results):1–3 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
objective cure rate— 84% vs 88% subjective cure rate— 83% in both groups operation length—20 vs 27 minutes length of hospital stay—no difference time to return to normal activity—no difference intraoperative blood loss— 48 vs 52 ml bladder perforation— 0.3% vs 5.5% major vascular injury—rare, no difference groin pain (after transobturator) vs suprapubic pain (after retropubic)—12% vs 1.7% postoperative voiding dysfunction— 4% vs 7% detrusor overactivity or de novo urgency with urgency incontinence—7% vs 6% quality of life improvement—no statistically significant difference
The authors close by stating, “The absence of standard methods for assessment of anti-incontinence procedures led to reporting of different rates of success for the same procedure. Moreover, because complete continence often seems not to be essential for patient satisfaction, scientists should tailor future randomized controlled trials on pa-
BENIGN PROSTATIC HYPERPLASIA
1845
tient-centered outcomes, taking into account patient expectations to achieve patient satisfaction.” Alan J. Wein, M.D., Ph.D. (hon.) 1. Novara G, Artibani W, Barber MD et al: Updated systematic review and meta-analysis of the comparative data on colposuspensions, pubovaginal slings, and midurethral tapes in the surgical treatment of female stress urinary incontinence. Eur Urol 2010; 58: 218. 2. Ogah J, Cody JD and Rogerson L: Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2009; 4: CD006375. 3. Latthe PM, Singh P, Foon R et al: Two routes of transobturator tape procedures in stress urinary incontinence: a meta-analysis with direct and indirect comparison of randomized trials. BJU Int 2010; 106: 68.
Benign Prostatic Hyperplasia Re: Associations Between Variants in the Cyclooxygenase 2 Enzyme Gene (PTGS2) and Development of Benign Prostate Enlargement J. L. St. Sauver, M. M. Lieber, S. L. Slager, D. J. Jacobson, M. E. McGree and S. J. Jacobsen Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota BJU Int 2011; 108: 1610 –1615.
Objective: To determine if polymorphisms in the cyclooxygenase 2 (COX-2) enzyme gene (prostaglandin synthase 2; PTGS2) were associated with development of benign prostate enlargement (BPE), and whether associations were modified by use of nonsteroidal anti-inflammatory drugs (NSAIDs). Materials and Methods: Participants were men residing in Olmsted County, MN, who were between 40 and 79 years of age in 1990 (N ⫽ 356). Prostate volume was measured by transrectal ultrasound and men reported all the medications that they were taking at the time of the examination. Men were followed biennially for 16 years. Ten tagging single nucleotide polymorphisms (SNPs) in the PTGS2 gene were typed using the Illumina GoldenGate™ Assay. Associations between SNPs and development of BPE (volume ⬎30 mL) were assessed by Cox proportional hazards models. Models were also stratified by NSAID use. Results: We observed significant associations between four polymorphisms in the PTGS2 gene and development of BPE (all P ⬍0.05). These associations were not observed among men who used NSAIDs. Conclusion: Variants in the PTGS2 gene may increase the risk of prostate enlargement, but the increased risk may be minimized by use of NSAIDs. Editorial Comment: It is widely accepted that inflammation either directly or indirectly contributes to prostate growth. The relationship to lower urinary tract symptoms is less understood. One could argue that lower urinary tract symptoms are in fact secondary to prostatitis and that therapies designed to alleviate inflammation may alleviate symptoms. Specifically, agents such as 5alpha-reductase inhibitors may reduce the inflammatory component of prostate growth with a resulting decrease in prostate specific antigen and prostate volume. Our group previously reported using finasteride to treat prostatitis.1 Could anti-inflammatory processes be identified and associated proxies tested that may herald prostate growth? These authors performed some innovative work looking at these associations. They previously reported that daily NSAIDs may have a protective effect against the onset of moderate/severe urinary symptoms and flow rates.2 COX-2 is a mediator of inflammatory processes, and higher levels of COX-2 may contribute to higher levels of prostatic inflammation. Moreover, these increases may partly arise secondary to variations in the COX-2 gene, PTGS2. In this study the authors postulate that polymorphisms in this gene may be associated with prostate enlargement and that these associations can be modified by use of NSAIDs. By tagging single nucleotide polymorphisms, they observed