Smith Blog

Watch Dr. Lee Richstone give a presentation on Multiparametic 3T MRI of the Prostate.

Will MR imaging provide the answers for prostate cancer dilemmas?

Lee Richstone, MD* and Eran Ben-Levi, MD**
The Smith Institute for Urology*
Diagnostic Imaging Center at the Center for Advanced Medicine**
The North Shore-Long Island Jewish Health System

Urologists and patients are faced with dilemmas at nearly every phase of prostate cancer management.  From prostate cancer detection, staging to treatment, many fundamental questions remain.  It is in this context that advances in prostate imaging could have a major impact in clinical practice with the potential to revolutionize the way we localize and stage prostate cancer, individualize treatment, and manage patients after treatment failure.  Multiparametric magnetic resonance imaging (MP-MRI), which integrates MR spectroscopic imaging (MRSI), diffusion weighted imaging (DWI), and/or dynamic contrast enhanced MRI (DCE) with traditional T2 weighted MRI, may be such an imaging breakthrough.

T2 MRI Scanning: Endorectal vs. Pelvic Phased Array, and 1.5 vs 3.0T Scanning
Standard T2-weighted MRI with 1.5 Tesla (T) scanners has been employed to detect and localize prostate cancer, which is characterized by decreased signal intensity compared to the normal peripheral zone.  The use of an endorectal coil in addition to external coils (pelvic phased array) allows for superior imaging.1,2  The use of 3.0T scanners offers increased spatial resolution, speed, and improved localization and staging.3  Clinically, endorectal MRI can incrementally improve upon preoperative nomograms in predicting seminal vesicle invasion (SVI) and extracapsular extension (ECE).4,5  Endorectal MRI has demonstrated clinical utility, altering the pre-surgical plan for neurovascular bundle preservation vs. resection in 39% of patients and 78% of high risk patients.6  Prostatic venous anatomy and membranous urethral length as evaluated with endorectal MRI have been correlated with estimated blood loss and postoperative continence, respectively, and some argue that MR based surgical planning has improved patient selection and pathological outcomes.7 However, significant limitations of T2 endorectal MRI exist, including limited sensitivity and specificity for detection of low stage, low grade disease, limitations in detecting prostate cancer in regions other than the peripheral zone, difficulty distinguishing prostate cancer from post-biopsy hemorrhage or prostatitis, and lack of inter-observer reliability.1,8-11   As a result, the value of T2 endorectal MRI as a single modality has been debated.11,12

Functional MRI Techniques: MRSI, DWI, and DCE
MRSI differentiates normal from cancerous prostate tissue by detecting differences in the concentration of various metabolites within the cytoplasm and extracellular space.10  Compared with normal tissue, prostate cancer is characterized by reduced or absent citrate and polyamines and elevated choline and creatine.13,14 Enthusiasm accompanied the early use of MRSI, which can be used to assess tumor location, volume, stage and may correlate with Gleason grade.2,15  Although some data has suggested that MRSI may be superior to T2 MRI alone, a multi-institutional study failed to demonstrate such advantages.14,16,17 Diffusion weighted imaging of prostate cancer is predicated on differences in the motion of water within normal vs. malignant tissue. Prostate cancer demonstrates reduced average water diffusivity compared with benign tissue, perhaps due to increased cell density within cancerous tissue.18 DWI detects prostate cancer with high spatial resolution and may be superior to T2 MRI alone in sensitivity and specificity of cancer detection and prediction of tumor aggressiveness.11,19  Dynamic contrast enhanced MRI takes advantage of tumor angiogenesis and increased microvascularity of malignant vs. benign tissue.  Malignant tissue differs from benign tissue with respect to microvessel density, blood flow, vascular morphology and permeability, and flow dynamics.12 Following gadolinium-DTPA contrast administration, prostate cancer typically demonstrates not only a greater peak enhancement, but also differs with respect to time to peak and washout.20 Interpretation of DCE can involve qualitative, semi-quantitative, or quantitative analysis.12 A growing body of literature suggests that DCE may significantly improve cancer detection, localization, and staging.11,16,21,22 Continuing research is aimed at determining the ideal DCE protocol and data analysis methodology in order to standardize the technique and allow for wider application.

Multiparametric MRI: Comprehensive Imaging with Clinical Applications
Multiparametric MRI integrates T2-weighted imaging with one or more functional technique (MRSI, DWI, and/or DCE) in a single study, with the potential to compensate for the shortcomings of each technique applied individually.  Combining modalities aims to increase the accuracy of MR-based imaging in a convenient single 60-minute study.  Moreover, scanning at 3.0T may improve the performance of individual and combined MRI techniques, and may even obviate the need for an endorectal coil, reducing the invasiveness of the study.11

Clinical applications of MP-MRI begin with prostate cancer diagnosis. For example, the management of patients with negative biopsies, yet persistently abnormal PSA values, is a common clinical dilemma.  Repeat standard biopsy has low yield of cancer detection and saturation biopsies may lead to increased morbidity and the detection of insignificant cancers.23  In a recent prospective, randomized trial of 180 patients with elevated PSA and negative prior biopsies, MP-MRI imaging (DCE/MRSI) led to increased detection of prostate cancer, with 62% being Gleason grade >7.23  A combination of T2, MRSI and DCE imaging had a PPV and NPV of 89% and 93%, respectively.  In this context, MP-MRI may aid urologists in the detection of significant cancers, and avoiding repeated biopsies in patients at lower risk.

Once prostate cancer is diagnosed, it is imperative to improve our ability to distinguish indolent from clinically significant tumors to reduce the extent of overtreatment.  The integration of MRI/MRSI with clinical parameters has been demonstrated to significantly improve the performance of nomograms in predicting insignificant prostate cancer.24  In the future, the further incorporation of DCE, and/or DWI at 3.0T into a single study could further improve our ability to select patients for active surveillance.  Moreover, one could imagine the use of an optimized MP-MRI protocol to avoid biopsy altogether in patients with an elevated PSA but low risk for clinically significant disease.  Such a non-invasive adjunct to screening could revolutionize our approach to prostate cancer detection, limit the diagnosis of indolent disease, and reduce the number of unnecessary biopsies and associated morbidity.

Multiparametric MRI at 3T allows for greater accuracy in detecting prostate cancer.25   With the potential to improve tumor localization, MP-MRI may help in the selection of patients for focal therapy, aid in treatment planning, and demonstrate the efficacy of ablation following minimally invasive or focally-based treatments.26  MP-MRI may be helpful in selecting those intermediate and high-risk patients who are appropriate for surgery and in tailoring the surgical approach.  Similarly, MP-MRI can aid in IMRT and brachytherapy dose-painting for improved treatment planning.7   Post-treatment, MP-MRI  may aid urologists with the common diagnostic challenge of determining whether treatment failure represents local or systemic disease. Various techniques, including DWI, DCE and MRSI have been used to aid in the detection and localization of recurrence after brachytherapy, external radiation treatment, and surgery, which may help in salvage treatment selection, and perhaps allow for focal or focally intensified salvage treatment in the future.7.12,27,28,29

Conclusions:
Multiparametric MRI has significant promise to aid clinicians with common prostate cancer dilemmas.  Currently, MP-MRI can be employed to help detect prostate cancer in the setting of multiple negative biopsies, evaluate cancer stage and guide treatment selection particularly in high risk patients, among other indications.  In the future, MP-MRI may have a major role in selecting patients for active surveillance and/or focal therapies. Future study is necessary to determine the optimal combination of functional techniques, and to develop standardized protocols for data acquisition and analysis.

REFERENCES

1.    Hricak H, White S, Vigneron D, et al.  Carcinoma of the prostate gland: MR imaging with pelvic phased-array coils verus integrated endorectal-ppelvic phased-array coils. Radiology 1994;193:703-709.
2.    Kurhanewicz J, Vigneron D, Carroll P et al.  Multiparametric magnetic resonance imaging in prostate cancer: present and future. Curr Opin Urol. 2008;18(1):71-77.
3.    Heijmink SW, Futterer JJ, Hambrock T, et al: Prostate cancer: body-array versus endorectal coil MR imaging at 3T-comparison of image quality, localization, and staging performance. Radiology 2007;244:184-195.
4.    Wang L, Mullerad M, Chen HN, et al. Prostate Cancer: incremental value of endorectal MR imaging findings for prediction of extracapsular extension. Radiology 2004;232:133-139.
5.    Wang L, Hricak H, Kattan MW, et al. Prediction of Seminal Vesicle Invasion in Prostate Cancer: Incremental Value of Adding Endorectal MR Imaging to the Kattan Nomogram. Radiology 2007; 242:182-188.
6.    Hricak H, Wang L, Wei DC, et al. The Role of Preoperative Endorectal Magnetic Resonance Imaging in the Decision Regarding Whether to Preserve or Resect Neurovascular Bundles during Radical Retropubic Prostatectomy. Cancer 2004;100:2655-63.
7.    Hricak H, Choyke PL, Eberhardt SC, Leibel SA, Scardino PT. Imaging prostate cancer:  a multidisciplinary perspective. Radiology 2007;243(1):28-53.
8.    Yu KK, Hricak H. Imaging prostate cancer. Radiol Clin North Am 2000;38:59-85.
9.    May F, Treumann T, Dettmar P, et al. Limited value of endorectal magnetic resonance imaging and transrectal ultrasonography in the staging of clinically localized prostate cancer. BJU 2001;87:66-69.
10.    Kurhanewicz J, Swanson MG, Nelson SJ, et al. Combined magnetic resonance imaging and spectroscopic imaging approach to molecular imaging of prostate cancer. J Magn Reson Imaging 2002;16:451-463.
11.    Macura 2008 Macura KJ. Semin Roentgenol. 2008 Oct;43(4):303-13
12.    McMahon et al, Magn Reson Imaging Clin N Am 2009;17:363–383.
13.    Wefer AE, Hricak H, Vigneron DB et al. Sextant localization of prostate cancer: comparison of sextant  biopsy, magnetic resonance imaging and magnetic resonance spectroscopic imaging with step section histology. J Urol 2000;164:400-404.
14.    Scheidler J, Hricak H, Vigneron DB, et al. Prostate cancer: localization with three-dimensional proton MR spectroscopic imaging: clinicopathologic study. Radiology 1999;213:473-480.
15.    Zakian KL, Sircar K, Hricak H, et al. Corretlation of proton MR spectroscopic imaging with Gleason score based on step-section patholoigic analysis afgter radical prostatectomy. Radiology 2005;234:804-814).
16.    Futterer JJ, Heijmink SW, Scheenen TW, et al. Prostate cancer localization with dynamic contrast-enhanced MR imaging and proton MR spectroscopic imaging. Radiology 2006;241:449-458.
17.    Weinreb JC, Blume JD, Coakley FV, et al. Prostate cancer: sextant localization at MR imaging and MR spectroscopic imaging before prostatectomy–results of ACRIN prospective multi-institutional clinicopathologic study. Radiology. 2009 Apr;251(1):122-33.
18.    Desouza NM, Reinsberg SA, Scurr ED, et al: Magnetic resonance imaging in prostate cancer: the value of apparent diffusion coefficients for identifying malignant nodules. Br J Radiol 2007;80:90-95.
19.    Miao H, Fukatsu H, Ishigaki T. Prostate cancer detection with 3-T MRI: comparison of diffusion-weighted and T2-weighted imaging. Eur J Radiol 2007;61:297-302.
20.    Bonekamp D, Macura KJ. Dynamic Contrast-Enhanced Magnetic Resonance Imaging in the Evaluation of the Prostate. Top Magn Reson Imaging 2008;19(6);273-284.
21.    Ocak I, Bernardo M, Metzger G, et al. Dynamic contrast-enhanced MRI of prostate cancer at 3 T:a study of pharmacokinetic parameters. AJR Am J Roentgenol 2007;189(4):849.
22.    Kim JK, Hong SS, Choi YJ, et al. Wash-in rate on the basis of dynamic contrast-enhanced MRI: usefulness for prostate cancer detection and localization. J Magn Reson Imaging 2005;22(5):639–46.
23.    Sciarra et al. Clin Cancer Res 2010;16(6):1875-1883).  Sciarra A, Panebianco V, Ciccariello M, Salciccia S, Cattarino S, Lisi D, Gentilucci A, Alfarone A, Bernardo S, Passariello R, and Gentile V.  Value of Magnetic Resonance Spectroscopy Imaging and Dynamic Contrast-Enhanced Imaging for Detecting Prostate Cancer Foci in Men With Prior Negative Biopsy. Clin Cancer Res 2010;16(6):1875-1883.
24.    Shukla-Dave A, Hricak H, Kattan MW, Pucar D, Kuroiwa K, Chen H, Spector J, Koutcher JA, Zakian KL and Scardino PT. The utility of magnetic resonance imaging and spectroscopy for predicting insignificant prostate cancer: an initial analysis. BJUI 2007;99:786-793.
25.    Turkbey B, Pinto PA, Mani H, et al. Prostate Cancer: Value of Multiparametric MR Imaging at 3 T for Detection–Histopathologifc Correlation. Radiology 2010;255(1):89-99.
26.    Larson et al, Urology 2003;62: 900–904.
27.    Haider MA, Chung P, Sweet J, Toi A, Jhaveri K, Me´ Nard C, Warde P, Trachtenberg J, Lockwood G, Math.M, and Milosevic M. Dynamic contrast-enhanced magnetic resonance imaging for localization of recurrent prostate cancer after external beam radiotherapy. Int. J. Radiation Oncology Biol Phys 2008;70(2): 425–430.
28.    Westphalen AC, McKenna DA, Kurhanewicz J, Coakley F. Role of magnetic resonance imaging and magnetic resonance spectroscopic imaging before and after radiotherapy for prostate cancer.J Endourol 2008; 22:789–794 87
29.    Sella T, Schwartz LH, Swindle PW, et al. Suspected local recurrence after radical prostatectomy: endorectal coil MR imaging. Radiology 2004;231:379-385.

Marina Ruzimovsky led a superb Pelvic Pain Support Group on February 28th.

Topics discussed included…

*The male chronic prostatitis/chronic patient: current management strategies

*New concepts of patient evaluation: Examination of the multiple facets of patient presentation (co-morbid conditions) rather than just the bladder or prostate.

*Novel and evolving approaches to the treatment of pelvic pain
The role of…
Cannabanoids
Liposomes
Nerve Growth Factor Immunoglobulin (Tanezumab)
Physical Therapy
Posterior tibial nerve stimulation
Trigger point injections
Botulinum toxin injections
New bladder instillations
Medications that can be administered through the vagina or rectum
Neuromodulation
Interferential transcutaneous nerve stimulation (iTENS)
Diet changes

* Two new studies for Interstitial Cystitis patients were discussed

-Caffeine study. Interstitial cystitis patients who feel that they are “coffee sensitive” are encouraged to participate. The project is designed to determine whether caffeine is actually the cause of IC related symptoms. If interested in participating, please contact Dr. Sadek (516) 734-8565.

-Nerve growth factor Immunoglobulin study (Tanezumab) for Interstitial Cystitis.  This is a study which will likely start in May 2010. For more information, please contact Monica Johnson, RN, our new clinical research coordinator, (516) 734-8515.

The Arthur Smith Institute for Urology proudly announces a new Interstitial Cystitis Support Group meeting called for Sunday, February 28, 2010 from 9AM-12PM.

The meeting will take place at The Arthur Smith Institute for Urology, conference room,
450 Lakeville Road Suite M-41, New Hyde Park, NY 11040

The last meeting was a huge success and we anticipate a terrific turnout this time as well.
Apart from a general lecture, we are trying to have patients break up into groups that have specific interests….so it’s important for everyone to make a great effort to participate!!! New patients and those patients outside our practice are invited.

The agenda will include a lecture by Marina Ruzimovsky, MSN, NP-C entitled:
What’s New in the World of IC: New Prevalence Studies, New Medications, New Treatments, Ongoing Research.

This will be followed by Questions and Answers

Important Items to be discussed will include:
1. Development of sub support groups, identification of leaders.
 a. Young Adult IC/PBS session
 b. Male IC/PBS, CP/CPPS
 c. Discussion of other special groups of interest
2. Specific topics for lectures for the future (ie, physical therapy, Vulvodynia, IBS)
3. Contact information - e-mail

Please RSVP at either DMcKay@lij.edu or MRuzimov@nshs.edu or (516)734-8565 (leave message)

Refreshments will be served

Recently, one of our faculty, Dr. Lee Richstone was honored to be involved as a faculty member at two advanced laparoscopy courses, one in India and the other in Los Angeles. Both courses were held for other physicians who wanted to learn advanced laparoscopic skills. In particular, they wanted to learn more about LESS surgery. LESS stands for Laparoendoscopic Single Site (LESS) surgery. This is a new approach to laparoscopic surgery, where the entire surgery is completed through the umbilicus (belly-button, or navel). The result is nearly scar-less surgery!

Dr. Richstone is one of the few who are leading the way in this exciting field. In fact, we have been pioneers in LESS donor nephrectomy, LESS pyeloplasty for obstructed kidneys, and LESS partial and complete nephrectomy. In particular, our experience with LESS partial nephrectomy is exciting. When patients have small kidney tumors that need to be surgically removed, a partial (not complete) kidney removal is required. This is called a partial nephrectomy. Dr. Richstone’s experience with performing this surgey ONLY through the belly-button may be the largest experience worldwide with this technique.  With time, there’s hope that this technique will offer the best possible cosmetic outcomes while sparing the majority of the remaining kidney, which is so vital.

In December Dr. Richstone was asked to travel to Nadiad, in India, to teach these techniques by giving lectures and performing live LESS surgery. It was a fascinating trip!  Surgeons came from all over the world, including Africa, India, Singapore, Japan, among other nations, to learn. It was a great “meeting of minds”! He performed 2 LESS operations over the 3 day course that helped many patients and their families. Medicine is an amazing occupation, rich with patient experiences, research opportunities, as well as incredible opportunities to work with collegues from across the globe. It is amazing how new technology “diffuses” so quickly to far corners of the world so rapidly! Dr. Manesh Desai was the organizer of the meeting, and the host. To him we are very grateful. More recently, Dr. Richstone was invited to participate in a similar course for the American Urological Association at a course held at the University of Southern California, with doctors from all over the United States, and as far as Korea, in attendance.

When it comes to new surgical approaches in surgery and urology, we need to do a better job of getting advanced techniques “out there” to the community.  For example, far too many patients get their entire kidney taken out when only part of it needs to be removed, and far too few patients are offered the advantages of a laparoscopic approach to surgery (ref 1). This is particularly for kidney surgery where the recovery is considerable shortened, with less pain. It is worthwhile to continue to strive to offer the same success rates for surgery, but strive for a “scarless” approach to improve patient sense of well-being, and cosmetic outcome (ref 2).  We at the Smith Institute for Urology have a long track record on the “cutting edge” of patient care and research, and will continue to do so with passion and vision.

Reference:
1) Richstone L, Kavoussi LR. Barriers to the diffusion of advanced surgical techniques. Cancer. 2008 Apr 15;112(8):1646-9.
2) Richstone L, Kavoussi L.”Less” is more. J Urol. 2007 Sep;178(3 Pt 1):752.

As many of our patients know, Dr. Barbara Shorter, EdD, RD, CDN Associate Professor of Nutrition and  Director of the undergraduate Nutrition Program at Long Island University, has been volunteering her time every other Friday to counsel IC patients.

Well…we are very happy to report that Dr. Shorter has now joined our faculty! She’ll be giving expert advice on the nutritional aspects of many other urological conditions such as kidney disease, kidney stones, interstitial cystitis, prostatitis, and urological cancers.

Barbara Shorter received her Doctorate in Nutrition Education from Teachers College, Columbia University.  She is a registered dietitian with the American Dietetic Association and is a Certified Dietitian/Nutritionist NYS.  Dr. Shorter is an Associate Professor in the Department of Nutrition at the CW Post Campus of Long Island University (LIU) and Director of the Didactic Program in Dietetics.  She recently joined the faculty of the Smith Institute for Urology where she provides nutritional counseling in facets of urology including, pelvic pain, prostate cancer, kidney stone disease, and renal failure.

Prior to Dr. Shorter’s positions in the Academic arena, she was Chief Dietitian for the Catholic Medical Center, and, Senior Nutritionist at the NYU Medical Center Hospital, NYC.

Welcome aboard Barbara!!

Men treated for inflammatory bowel disease with Sulfazalazine have drug related impairment in sperm quality that often persists after cessation of the drug. This had prompted pharmaceutical companies to develop other “sperm friendly” treatment options. The most frequent age of onset of the inflammatory bowel diseases including idiopathic chronic inflammatory bowel disease (IBD), Crohn’s disease (CD) and Ulcerative Colitis (UC) is between 15 to 30 years of age. This range, of course, coincides with the peak reproductive years. Therefore, it makes good sense that the effect on male fertility of any drug treatment should be known. Azathioprine and 6-Mercaptopurine (6-MP) are effective immunosuppressive agents commonly used for the long term control of UC and CD in the steroid dependent patient and are focus of this article.

Azathioprine is converted to 6-mercaptopurine which acts to decrease cell metabolism and DNA biosynthesis. A study by Russell and Hunsicker (Study of the base analog 6-mercaptopurine in the mouse specific-locus test., Mutat Res. 1987 Jan;176(1):47-52.) found that in mice 6-Mercaptopurine caused chromosomal damage (both structural and numerical) in all stages of development of the male germ-cell. This data was again confirmed by Witt and Bishop (Mutagenicity of anticancer drugs in mammalian germ cells., Mutat Res. 1996 Aug 17;355(1-2):209 34). In a study in rats, a dose dependent decrease in sperm concentration, damage to the seminiferous tubules and a lowering of testosterone was found with Azathioprine therapy (Iwasaki M, Fuse H, Katayama T., The effects of cyclosporine azathioprine and mizoribine on male reproduction in rats, Nippon Hinyokika Gakkai Zasshi. 1996 Jan;87(1):42-9). In addition, in a study in mice, spermatogenesis and fertility was also decreased (Sykora I. Dominant-lethal test of 6-mercaptopurine: dependence on dosage, duration and route of administration. Neoplasma. 1981;28(6):739-46).

There is some, but unfortunately not much, data available on the effect of these agents on sperm production and sperm function in man. A study by Dejaco et al suggested that men treated with Azathioprine have no change in semen quality and
implied that fertility was also unaffected (Gastroenterology. 2001 Nov;121(5):1048 53. Azathioprine treatment and male fertility in inflammatory bowel disease. Comment in: Inflamm Bowel Dis. 2002 May;8(3):234-5). In this study, paired data wasn’t examined. In contrast, a case study by Sills and Tucker found markedly impaired semen parameters in a single patient who had conceived twice with his partner prior to three months of therapy with 6-MP (First experience with intracytoplasmic sperm injection for extreme oligozoospermia associated with Crohn’s disease and 6-mercaptopurine chemotherapy. Asian J Androl. 2003 Mar;5(1):76-8).

Much more data is needed in humans. Many questions remain unanswered; Are the effects of these drugs in man similar to those found in rodents? Is it the medication used or the underlying disease that has a greater effect on sperm? Are the effects seen reversible, and if so over what time period? Additional research is needed to define the effect of these (and other) drugs used in the treatment of inflammatory bowel disease in reproductive-aged men. Until these studies are done, I feel it is advisable to discuss the potential for impairment in fertility and offer sperm banking to reproductive aged men prior to long term treatment with Azathioprine or 6-Mercaptopurine.

Bruce R. Gilbert, MD, PhD
Director, Reproductive and Sexual Medicine
The Smith Institute for Urology
North Shore LIJ Health System
7/26/09

The American Urological Association Annual meeting in Chicago (April 25th – April 30th) was a huge success for patients suffering from pelvic pain. Some of the latest news…

1.    Various differences may exist in urinary protein expression between interstitial cystitis (IC) patients and those without IC. This suggests that “urinary proteomics” may provide insight into the cause of IC and/or aid in the development of new “markers” for this condition.
2.    Nerve growth factor was found to be elevated in the urine of IC patients and in patients with overactive bladder and even in patients with varied lower urinary tract symptoms.
3.    Patients with IC appear to have significant biosocial impairment as compared to the population at large. Also, conditions such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome were more frequently seen in the IC population.
4.    The Rand Interstitial Cystitis Epidemiology study evaluated almost 100,000 US households and found the prevalence of IC type symptoms in women to be 3-6%, a significantly higher prevalence than previous studies. This suggests that IC symptoms may exist in over 4 million women in the United States!
5.    Botulinum toxin A (100 units) into the bladder base (trigone) improved the symptoms of all 17 patients in one study. At 9 months follow up, 7 patients requested another injection due to return of symptoms.
6.    In another Botulinum toxin A related study, Botulinum toxin A appeared to enhance the clinical effect of bladder hydrodistention.
7.    Antiproliferative factor (APF) is a chemical found in the urine of most IC patients and may be a cause of symptoms. Two new agents have shown promise as APF inhibitors in the laboratory setting.
8.    Both IC patients and patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) had a high prevalence of food sensitivities, but IC patients still had about twice the prevalence as the CP/CPPS patients.
9.     A clinical phenotyping system termed “UPOINT” (Urinary, Psychosocial, Organ specific, Infection, Neurologic/Systemic, Tenderness of pelvic floor muscles) was developed to better understand the cause of and best therapies for CP/CPPS.
10.    In a randomized, double blinded study, pregabalin (Lyrica®)  was not found to be better than a placebo group in the treatment of CP/CPPS…BUT..when evaluating “secondary endpoints” such as global improvements, significant differences where found, suggesting a role for this medication in the treatment of CP/CPPS.

For this information and more, please visit the Pelvic Pain section of this website.

Robert Moldwin, MD
Associate Professor of Clinical Urology
Hofstra University School of Medicine
Director, Pelvic Pain Center
The Arthur Smith Institute for Urology
Long Island Jewish Medical Center

In 1953, John Hunt led a British expedition to climb Mount Everest that unfortunately had to turn around within 300 feet of the summit.  Although the group failed its task, they defined a route and introduced a technique for carrying extra oxygen that allowed the New Zealander Edmund Hillary to reach the summit a few days later. Hillary became Sir Hillary and the accomplishment was celebrated around the globe.

Several steps have been taken in the climb towards a true Natural Orifice Transluminal Endoscopic Surgery (NOTES) nephrectomy. This means removing organs through a natural orifice such as the mouth, rectum, urethra or vagina.  Previous reports demonstrate that kidney removal through the vaginal vault is feasible.

Is NOTES the summit of “Everest” or is it Base Camp? The answer is both. NOTES has fulfilled the dream of eliminating a visable incision for extirpative renal surgery. However, there are growing series of Laparoendoscopic Single-Site Surgery (LESS) nephrectomies that have shown only cosmesis as the advantage to minimizing the incision. Until a series of NOTES nephrectomies is evaluated it is uncertain whether there will be any additional benefit to the patient. The major issues of surgery still remain with postoperative ileus, fatigue and discomfort coming from the actual renal dissection which does not change based on location of trocar placement.

This kind of surgical exploration needs to be supported.  However, the real surgical “Everest” will be a quantum leap, a total replacement of our current notion of invasive extirpative surgery.  We should never take our eyes off this ultimate prize.

Louis R. Kavoussi, M.D.
Professor and Chairman
Smith Institute for Urology
Hofstra School of Medicine
North Shore-LIJ Health System
Long Island, NY

Dr. Moldwin was an invited panelist for the National Institute’s of Health’s (NIH) Office of Research on Women’s Health (ORWH) held March 4-6th, 2009. The meeting was entitled “Moving into the Future: New Dimensions and Strategies for Women’s Health Research.” It was designed to help the NIH formulate its research priorities for the next 10-20 years. The meeting covered all areas of women’s health. Dr. Moldwin was present to plead for more dollars for research projects that would help interstitial cystitis patients. Also present representing the interests of IC patients was Barbara Gordon, the Executive Director of the ICA.

Some suggestions that came from the “Chronic Pain Syndromes” panel that Dr. Moldwin attended included:

1. Developing research strategies to investigate chronic pain syndromes as a “systemic” problem (that has manifestations in multiple systems in the body). This may help better establish why so many patients with IC also have problems like fibromyalgia, irritable bowel syndrome, migraine headaches, Sjögren’s Syndrome, vulvodynia, chronic fatigue syndrome, etc. This topic received the most attention and discussion.
2. Developing better ways to conduct trials for new therapies.
3. Developing better animal models for chronic pain syndromes. We had a very long discussion about this very complex topic.
4. Exploring issues related to clinician- patient interactions in the chronic pain patient. Differences in how people describe their difficulties which may vary on the basis of previous experiences, social environment, or sex.
5. The effect that factors such as hormones and diet may have on these pain syndromes.
6. The great need for the development of a database system where clinical data from patients can be pooled together from multiple institutions.

Other topics that were discussed included:

1. The need for chronic pain syndromes (including IC) to be included in the curriculum of medical schools. Currently, medical students typically graduate without even hearing of fibromyalgia, IC, vulvodynia, etc… no less being taught to manage such patients. Without a basic understanding of these conditions from their basic training, how do we expect any of these bright people to treat or become researchers in this area? We suggested that the ORWH take a role in mandating discussion of these topics in medical school curricula.
2. Pharmaceutical companies apparently have lots of data on various medications which may show promise as future treatments for patients in pain. We would like to see some of these data voluntarily released, thereby giving researchers some groundwork for the development of future therapies.