Faculty Spotlight: Kevin Billups, MD and the Men’s Health & Vitality Program

Erectile dysfunction (ED) and low testosterone (also known as hypogonadism) are common health issues for aging men. Not only are ED and low testosterone related in that they both present in aging men, but low testosterone may contribute to ED and both have implications for overall cardiovascular health.

Important statistics regarding ED, hypogonadism and cardiovascular (CV) health:

• ED and sexual dysfunction is the most specific symptom of late-onset hypogonadism, which is associated with increased CV events and death [1,2]
• Normal sexual activity throughout adult life is associated with decreased CV events [3]
• ED precedes coronary artery disease in 50% of affected subjects, therefore ED indicates early heart disease [3]
• ED predicts CV disease and overall health independent of other known risk factors for CV disease [4]

 
Kevin Billups, MD, is the Director of the Men's Health and Vitality Program at Johns Hopkins. Dr. Billups is very aware of the relationship between ED, low testosterone and overall health. "The first thing I do," he says, "is point out that these problems don't occur in a vacuum. What else is going on?"

For example, if a man between 40 and 50 has ED, growing evidence suggests that he could have a nearly fifty-fold increased risk of developing heart disease over the next 10 years. Therefore, treating the ED is the equivalent of putting a band aid on a lacerated blood vessel – it does not treat the underlying issue and risks of subsequent serious health issues. Billups refers many of his patients to general urologists, primary care physicians, sleep specialists or preventive cardiologists for further testing when needed. "We're offering very integrated, multidisciplinary care." ED is the avenue to get these at-risk men into the doctor's office, from there these patients undergo a thorough risk assessment competing illnesses and can be directed to treat the underlying issues causing their ED.

 Low testosterone is another cause of concern for many men. It doesn't help that many have seen advertisements for testosterone-boosting supplements promising to cure all—except, Billups notes, the underlying cause. "Men think it's just a sex drive thing, but a lot of what we see is related to other common chronic conditions. Treating that one symptom without finding out the whole story would not be a good idea." Diabetes or even prediabetes can lower testosterone; conversely better control of blood sugars in diabetic men can lead to improvements in testosterone levels.[6] Other signs of metabolic syndrome including a large waist circumference, abnormal lipids and blood pressure can also affect testosterone. Having a big gut specifically plays a role, Billups adds. "Having a waist circumference greater than 40 inches lowers testosterone. Fat, especially belly fat, makes the enzyme aromatase, which converts testosterone to estrogen.

The most common symptoms of low testosterone are ED, fatigue, feeling sluggish, loss of strength or endurance, daytime sleepiness, even cognition issues. "We can document with a blood test that your testosterone is low, but what's going on with your cardiovascular status, your thyroid? Is there any depression going on? If a man has obstructive sleep apnea and low testosterone, he really needs to get the apnea addressed first, because that can make the testosterone worse."

The story was extracted from "Erectile Dysfunction and Low Testosterone Offer Gateway to Men's Health" in Johns Hopkins Urology: News for Physicians, Winter 2015 by Johns Hopkins Medicine.

 
[1] F.C. Wu, A. Tajar, J.M. Beynon, et al. Identification of late-onset hypogonadism in middle-aged and elderly men. N Engl J Med, 363 (2010), pp. 123–135.
[2] G. Corona, G. Rastrelli, M. Monami, et al. Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study. Eur J Endocrinol, 165 (2011), pp. 687–701.
[3] S.A. Hall, R. Shackelton, R.C. Rosen, A.B. Araujo. Sexual activity, erectile dysfunction, and incident cardiovascular events. Am J Cardiol, 105 (2010), pp. 192–197.
[4] F. Montorsi, A. Briganti, A. Salonia, et al. Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease. Eur Urol, 44 (2003), pp. 360–364
[5] A. Salonia, G. Castagna, A. Sacca, et al. Is erectile dysfunction a reliable proxy of general male health status? The case for the international index of erectile function-erectile function domain. J Sex Med, 9 (2012), pp. 2708–2715
[6] Ho CH, Jaw FS, Wu CC, Chen KC, Wang CY, Hsieh JT, Yu HJ, Liu SP. The Prevalence and the Risk Factors of Testosterone Deficiency in Newly Diagnosed and Previously Known Type 2 Diabetic Men. J Sex Med. 2014 Dec 2. doi: 10.1111/jsm.12777. [Epub ahead of print]

Faculty Spotlight: Stephen Schatz, Innovative Treatments of BPH

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are incredibly common.  Approximately 40% of 50-year old men with have histologic evidence of BPH at autopsy, this number increases to 80% for 80-year men.  Over the same time period, mean prostate volume increases from an average baseline of 15-25 grams at age 50 to 25-40 grams at age 80.  In addition, the percentage of men with moderate-to-severe LUTS increases with age.[1]  When LUTS are bothersome, treatment options for BPH include medication and, when medications fail, surgery.

Stephen Schatz, MD

The traditional surgery for BPH is the transurethral resection of the prostate (TURP).   This operation has long been considered the "gold standard" for symptom relief.  But now, instead of chipping away at the prostate, says urologist Stephen Schatz, "we are doing far more procedures using either bipolar electrosurgical vaporization or laser vaporization techniques."  Essentially, vaporization destroys prostatic tissue using a high-energy source that coagulates as it destroys, preventing bleeding.

"Vaporization techniques are demonstrated to be safer than traditional TURP, with results that are entirely comparable" in terms of the durability and degree of symptoms relief, and retreatment rates are quite low.[2]  

With vaporization, the only significant downside is temporary worsening of irritative urinary symptoms (frequency, urgency and burning) immediately afterward.  But, Schatz says, "I have found this always gets better, and the long-term improvement is profound in most men.  It's a great alternative to long-term medical treatment," which takes longer to achieve an effect and does not provide as great a relief of symptoms.

Although Schatz performs all the surgical procedures, he prefers bipolar vaporization.  "I can see the prostate clearly as I work, without bleeding obscuring my view," he says.  Immediately afterwards, he adds, "the urine is almost always clear."  Only about 5% of patients stay overnight.  In addition, the rates of erectile dysfunction lower than with TURP because there is no electricity arcing outside the prostate and potentially injuring the cavernous nerves.

For men with BPH and low-risk prostate cancer...

Schatz and colleagues are even able to use vaporization on men with low-risk prostate cancer in Johns Hopkins' active surveillance program who are significantly bothered by LUTS.  "We continue to follow them regularly with biopsies and PSA tests," he says, "but the cancer doesn't get in the way of their treatment."

For men with very large prostate...

Schatz performs a simple prostatectomy - enucleation of the prostate, going in through a skin incision and through the bladder - robotically.  In a case series of more than 50 patients, Johns Hopkins urologists have reported outcomes that are comparable to the results from open surgery, but with clear decreases in perioperative blood loss.

For men who are poor candidates for surgery...

Schatz and interventional radiologist Mark Lessne are conducting a multicenter trial comparing prostatic artery embolization with traditional TURP, using very rigorous outcome measures, measuring prostates and performing urodynamics before and after, and tracking quality of life indices to see how patients respond.  The angiography procedure, done through the femoral artery, takes less than three hours and has "essentially no blood loss and no absorption of any fluids," Schatz says.  Symptoms improvement comes gradually as prostate tissue dies.  Click on the following link to see our prior blog entry on prostatic artery embolization.

Schatz suspects that within a few years, this treatment will be offered to men who "may not be candidates for even minimally invasive surgery, but who have significant symptoms not helped all that much by medications."

This blog entry is extracted and modified from the "Johns Hopkins Urology: News for Physicians from Johns Hopkins Medicine," Spring 2014.

[1] Roehrborn, Claus G., MD.  Benign Prostatic Hyperplasia : Etiology, Pathophysiology, Epidemiology, and Natural History [Book] Campbell-Walsh Urology, chapter 91, Pages 2570-2610.e10 Copyright © 2012, 2007, 2002, 1998, 1992, 1986, 1978, 1970, 1963, 1954 by Saunders, an imprint of Elsevier Inc.
[2] Teng J1, Zhang D, Li Y, Yin L, Wang K, Cui X, Xu D.  Photoselective vaporization with the green light laser vs transurethral resection of the prostate for treating benign prostate hyperplasia: a systematic review and meta-analysis.  BJU Int. 2013 Feb;111(2):312-23. doi: 10.1111/j.1464-410X.2012.11395.x. Epub 2012 Nov 13.

2014 American Urological Association (AUA) Annual Meeting: Kickoff

Today marks the start of the Annual American Urological Association (AUA) Annual Meeting in Orlando, Florida.  This annual meeting hosts approximately 20,000 urologists from around the world and offers an exciting forum in which new guidelines are released for a variety of disease states, new research and breakthroughs in urology are showcased, and advances in technology are displayed for everyone to see.

The Brady Urological Institute is once again represented very strongly at this year's meeting.  Below you can find links to calendars showing (1) the faculty appearances and presentations throughout the meeting and (2) each poster, podium and video session where urology research from Johns Hopkins is being presented.

In total, there are 17 faculty presentations and 45 research presentations over the 5 day meeting.  Some of the highlights include:

FACULTY PRESENTATIONS

• Dr. H Ballentine Carter will be addressing the Early Detection of Prostate Cancer and discussing last year's AUA Prostate-Specific Antigen Best Practice Statement at:
• Plenary II: Crossfires in Urology on Friday, May 16th at 1pm in the Chapin Theater.
• American Society for Men's Health (ASMH) Meeting on Monday, May 19th at 230pm in the Orange County Convention Center (OCCC), Room W224G.
• Society Presidential Addresses:
• Dr. Arthur L. Burnett, Sexual Medicine Society of North America (SMSNA), Saturday, May 17, 730am Hyatt Regency BR R&S
• Dr. Jennifer Dodson, Society of Women in Urology (SWIU), Sunday, May 18th, 630am in the Hyatt Regency Orlando BR M
• Dr. Brian Matlaga will be discussing the management of kidney stones at:
• Confederacion Americana de Urologia (CAU), "Overview of Renal Calculi," Saturday, May 17th at 130pm in the Valencia Board Room of the OCCC.
• Plenary I, "Point Counterpoint: Sterile Urine Before PCNL, One Week of Antibiotic Therapy," Monday, May 19th at 933am in the OCCC Valencia Ballroom.
• ROCK Society (Research on Calculus Kinetics), "What is the Preferred Management of Proximal Ureteral Stones: Medical Expulsive Therapy, Surgical Therapy," on Monday, May 19th at 420pm in the OCCC, W314.
• Dr. Ken Pienta will be giving the Coffey Lecture at the joint SBUR (Society for Basic Urologic Research)/ SUO (Society of Urologic Oncology) Meeting on "Cancer and Metastases: What Ecology Can Teach Us."
• Dr. Alan Partin will be discussing "Prostate Cancer Tissue Methylation as a Marker for Repeat Biopsy: Update from the MATLOC and DOCUMENT Trials" at the joing BAUS/BJUI/USANZ Meeting, Sunday, May 18th, at 220pm in the Hyatt Regency BR P.

RESEARCH PRESENTATIONS

• Dr. Trinity Bivalacqua's group will be presenting over 13 posters and podiums on a variety of topics incuding urothelial cancer, penile cancer, erectile dysfunction and return of sexual function after pelvic surgery.  Two of those posters were selected as Outstanding Posters and will be presented on Saturday, May 17th at 1pm in the OCCC W303.
• Baras, Gandhi, Munari, Faraj, Hoque, Schoenberg, Bivalacqua and Netto.  "Identification and Validation of Protein Biomarkers of Response to Neoadjuvant Chemotherapy in Muscle Invasive Urothelial Carcinoma."
• Hannan, Liu, Hoke, Burnett and Bivalacqua. "Rho-kinase inhibition prevents nNOS uncoupling in the MPG, erectile dysfunction and increases neuronal outgrowth following cavernous nerve injury."
• The Kidney Cancer Research Team, led by Dr. Mohamad Allaf will be presenting 11 posters and podiums.  Highlights include:
• Results from the Multi-Institutional Consortium of Robotic Partial Nephrectomy.
• Assessment of complications following Radical and Partial Nephrectomy in NSQIP.
• Robotic Retroperitoneal Lymph Node Dissection for Stage 1 Testis Cancer.
• Dr. Phillip Pierorazio will be championing the six presentations from the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry looking at comparative oncologic outcomes, selection criteria, growth kinetics and quality of life for patients undergoing active surveillance or surgery for small kidney tumors.

Click here to download the full calendar of Faculty Presentations.

 Click here to download the full calendar of Research Presentations.

Faculty Spotlight: Arthur Burnett, Restoring Sexual Function

Arthur L. Burnett, II, MD, MBA
Patrick C. Walsh Distinguished Professor of Urology
Director, Basic Science Laboratory in Neurourology
Director, Sexual Medicine Fellowship Program
Faculty Member, Cellular and Molecular Medicine
Graduate Training Program

Arthur L. Burnett, II, MD, MBA, surgeon and neurourologist, is a pioneer in the area of sexual medicine.  Many of his patients are men with prostate cancer who are worried about impotence after radical prostatectomy.  But other men of all ages come to see Burnett for help with issues ranging from ejaculatory disturbances, to libidinal problems, and may need treatment ranging from pharmacotherapy, to injection therapy, to prosthetics, to genital reconstruction following injury or cancer.

Protecting Nerves: Burnett's discovery with Johns Hopkins neuroscientist Solomon Snyder that nitric oxide plays a crucial role in erection led to development of the drug Viagra for erectile dysfunction.[1]  For nearly three decades, much of his lab and clinical work has focused on protecting the integrity of the neurovascular bundles responsibile for erection, easily damaged even in the "nerve-sparing" radical prostatectomy developed by Johns Hopkins urologist Patrick Walsh, MD.  "It may even be from traction, or even that the adjacent dissection somehow exposes the nerves to injury," Burnett says, "Something causes them to sustain an inflammatory setback."

In groundbreaking studies of rats with nerve injury and erectile dysfunction similar to that found in men after radical prostatectomy, he has tested many inflammation-fighting agents and growth factors designed to "preserve, nourish, regenerate and restore nerves to normal function."  One of these is an agent used to combat anemia, erythropoeitin (EPO).  Burnett previously led studies investigating the effects of EPO on erectile function recovery in a rat model of cavernous nerve injury;[2] and now he is investigating those promising results in humans.  In a randomized, controlled clinical trial, still actively enrolling patients, Burnett is studying EPO's ability to enhance nerve function.  EPO is injected the day before, the day of, and the day after radical prostatectomy.

In other work, Burnett has targeted the fragile network of blood vessels and chambers within the penis.  Even though they're not directly traumatized by surgery, "these structures may degenerate or shrivel," he says, "and thus contribute to poor recovery of erectile function in some men after surgery."  To fight this, Burnett is testing such blood vessel-strengthening agents as angiotensin II type 1 receptor antagonists.  In another clinical trial, he is testing an external vibration nerve-stimulatory device, which he helped develop, that may be applied under a specific protocol after surgery.

If you, a loved one, or a patient is interested in one of Dr. Burnett's trials, please call the Urology Clinic at the Brady Urological Institute (410) 955-6100 for an appointment with Dr. Burnett.

Help for incontinence and impotence: Having both urinary incontinence and impotence after radical prostatectomy should be a rare complication, but some men find themselves in this situation and need help.  For the last 13 years, Burnett has offered a successful operation that restores urinary continence and potency at the same time --- implantation of an inflatable penile prosthesis and an artificial urinary sphincter.  "It provides efficient and rapid resumption of both functional disorders, " he says.

Burnett is also conducting further research into utilization and prediction modeling for penile prosthesis surgery.  Dr. Burnett explains,

"Our goal is to approach everything we do thoughtfully and rigorously, so that we can make advances based on what is scientifically meaningful."

This blog entry is extracted from the "Johns Hopkins Urology: News for Physicians from Johns Hopkins Medicine," Spring 2014.




[1] Burnett AL, Lowenstein CJ, Bredt DS, Chang TS, Snyder SH.  Nitric oxide: a physiologic mediator of penile erection.  Science. 1992 Jul 17;257(5068):401-3.
[2] Allaf ME, Hoke A, Burnett AL.Erythropoietin promotes the recovery of erectile function following cavernous nerve injury.J Urol. 2005 Nov;174(5):2060-4.