This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Aug 2021This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001809AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail I sometimes offer the opinion that robotic assisted laparoscopic prostatectomy (RALP) for a straightforward surgical case offers no substantial benefit compared to the open operation in the hands of an experienced and skilled surgeon. The point is rather moot nowadays since experienced open radical prostatectomy surgeons are disappearing. However, almost everything which increases complexity of the procedure—patient obesity, prior radiation, previous inguinal hernia surgery with mesh, a small volume prostate, to name a few—enhances the advantages of the robotic approach. This also applies to prior prostate surgery such as transurethral resection (TURP). With open surgery, the thin anterior prostate is easily disrupted, the junction with the trigone may be difficult to distinguish, and the small volume may make prostate borders indistinct. Some of these issues apply with RALP but are less of a factor. In this issue of The Journal, Leyh-Bannurah et al (page 308) from Germany evaluated over 5,000 patients who underwent RALP and compared those without prior prostate surgery to a group who had previous TURP or laser enucleation (LE-P).1 No difference in complications was observed and oncologic outcomes including margin status and biochemical recurrence rates were similar. Both continence and potency results, though, were statistically inferior in the TURP/LE-P patients. Omitting Systematic Biopsy of the Prostate for PI-RADS™ 5 and Prostate Specific Antigen Density >15% There remain differences of opinion about whether systematic biopsy is required in men undergoing magnetic resonance imaging targeted biopsy of suspicious areas. Tafuri et al (page 289) from Japan refined the discussion by focusing on patients with PI-RADS 5 lesions and a prostate specific antigen density >0.15 ng/ml.2 In this group, systematic biopsy added 2% to the overall prostate cancer detection rate compared to targeted biopsy alone and 4% for clinically significant cancers. Whether a 4% benefit for significant cancers justifies systematic biopsies could be a matter of interpretation, but the authors concluded they could be omitted in this specific patient population. Performance Feedback and Radical Prostatectomy Outcomes Hospitals increasingly are providing feedback to their surgeons on performance based on operative results. This can help surgeons identify areas where focus may help provide better results for patients. Also, there is the known Hawthorne effect—just knowing someone is tracking outcomes may influence individuals to attempt to improve compared to benchmarks. Kumar et al (page 346) from Canada investigated results at their hospital where a surgeon report card (SuRep) has been implemented which includes data on postoperative erectile function, margin status, and potency.3 Interestingly, at 1 year there was no noticeable improvement in any parameter and a statistically significant decrease in the continence rate after introduction of the SuRep. Perhaps more specific details about how surgeons actually can improve results are needed. Mycoplasma and Ureaplasma Molecular Testing for Painful Lower Urinary Tract Symptoms Ureaplasma and Mycoplasma are genitourinary colonizers but it is uncertain if they play a causative role in patients with chronic lower urinary tract symptoms (LUTS). In a multicenter community hospital cohort, Souders et al (page 390) found that quantitative polymerase chain reaction (PCR) identified both organisms in similar proportion in symptomatic and asymptomatic women (25% of controls and 27% with LUTS) and men (9.5% and 3.3%, respectively).4 There was a statistically significant negative correlation with a variety of specific LUTS such as dysuria and urethral pain. The authors concluded that PCR-based Mycoplasmataceae detection has little diagnostic benefit in assessing chronic irritative LUTS. Outcomes in Clinical N0 Squamous Cell Carcinoma of the Penis According to Nodal Management Men with clinically negative inguinal nodes and a diagnosis of penile squamous cell carcinoma must decide whether to undergo inguinal lymph node dissection (ILND). In a series of 296 patients Nazzani et al (page 354) from Italy compared early vs delayed ILND and the role of dynamic sentinel node biopsy (DSNB).5 Adjusted 5-year inguinal relapse-free survival was statistically better in both the early ILND and DSNB groups, as was cancer specific survival. The authors advocate for DSNB and selective ILND in patients with clinically negative nodes. Outcome Differences after Cystectomy between Patients with De Novo Muscle-Invasive Bladder Cancer and Progressors Some patients present with muscle invasive bladder cancer (MIBC) while others develop progression while undergoing treatment for what was initially nonMIBC disease. Lusty et al (page 260) from Canada compared results of cystectomy for patients with de novo MIBC compared to a group with progression.6 Adjustment by stage revealed no difference in outcomes between the groups. A limitation noted by the authors is that the comparison doesn’t include patients who may have had progression but never underwent cystectomy. Active Surveillance for Risk Stratification of All Small Renal Masses Lacking Predefined Clinical Criteria for Intervention Menon et al (page 229) from Buffalo, New York followed 123 patients with a small renal mass with surveillance.7 Defined criteria for progression requiring intervention were utilized. With a median followup of 31 months, none developed metastasis but 30% met criteria for progression. Of those who underwent intervention 62% had pT3 disease or nuclear grade 3-4 tumors. None proved to be benign. Study of Ketorolac vs Opioid for Pain after Endoscopy After ureteroscopy, pain is the most common reason for unplanned emergency department visits. While appropriate use of postoperative analgesics is important, avoidance of opioid is desirable. In a multi-institutional study by Fedrigon et al (page 373) patients were randomized and blinded post ureteroscopy to either oxycodone (5 mg) or ketorolac (10 mg) taken as needed with 3 nonblinded oxycodone rescue pills for breakthrough pain.8 There was no difference between groups in postoperative pain scores, study medication, or rescue pain use. Patients receiving ketorolac had significantly fewer days confined to bed. The conclusion that routine opioid use after ureteroscopy should not be used seems sound. Contemporary Trends and End-Results of NIH Grant Funding to Departments of Urology in the U.S. Research Scholar grants from the Urology Care Foundation as well as other organizations are designed to support and encourage investigators within the domain of urology and have been crucial in accomplishing this. As a report by Hakam et al (page 427) from San Francisco, California and Baltimore, Maryland shows, though, the field still lags behind compared with other subspecialties, including within surgical disciplines.9 Over the time period of 2010–2019, National Institutes of Health grants to urology departments decreased in total funding by 15.6%. Over half of the grants went to a principal investigator (PI) with a urologic oncology specialty; 21.6% of all grants had a female PI and they were more likely to be a PhD basic scientist than males (64% vs 38%). Impact of Frailty on Outcomes of Sling Surgery Frailty is predictive of adverse outcome for many surgical procedures. Using the American College of Surgeons National Surgical Quality Improvement Project® (NSQIP®) database from 2013–2016, Medendorp et al (page 382) in a multicenter study identified 25,887 women undergoing either isolated sling (Group 1) or sling with concomitant prolapse repair (Group 2).10 Frailty was present in 9.3% and 10.2%, respectively. Both frailty and increased age were associated with longer length of stay but only frailty predicted 30-day hospital readmission. Efficacy of a Novel Penile Traction Device in Improving Penile Length and Erectile Function Postprostatectomy Maintenance of penile length is a significant concern of patients after radical prostatectomy, especially those who are sexually active. In a multicenter randomized trial by Toussi et al (page 416), a penile traction device was used and compared to a control group.11 Importantly, measures of stretched penile length were performed by blinded assessors. There was a significant improvement in both subjective and objective penile length in the traction group and a higher sexual satisfaction score. References 1. : Perioperative and postoperative outcomes of robot-assisted radical prostatectomy in prostate cancer patients with prior transurethral subvesical deobstruction: results of a high-volume center. J Urol 2021; 206: 308. Link, Google Scholar 2. : Systematic biopsy of the prostate can be omitted in men with PI-RADS™ 5 and prostate specific antigen density greater than 15%. J Urol 2021; 206: 289. Link, Google Scholar 3. : Performance feedback may not improve radical prostatectomy outcomes: the Surgical Report Card (SuRep) study. J Urol 2021; 206: 346. Link, Google Scholar 4. : Mycoplasma and Ureaplasma molecular testing does not correlate with irritative or painful lower urinary tract symptoms. J Urol 2021; 206: 390. Link, Google Scholar 5. : Clinical outcomes in clinical N0 squamous cell carcinoma of the penis according to nodal management: early, delayed or selective (following dynamic sentinel node biopsy) inguinal lymph-node dissection. J Urol 2021; 206: 354. Link, Google Scholar 6. : No outcome differences after cystectomy between patients with de novo muscle-invasive bladder cancer compared to progressors: a retrospective population-based study. J Urol 2021; 206: 260. Link, Google Scholar 7. : Active surveillance for risk stratification of all small renal masses lacking predefined clinical criteria for intervention. J Urol 2021; 206: 229. Link, Google Scholar 8. : SKOPE—Study of Ketorolac vs Opioid for Pain after Endoscopy: a double-blinded randomized control trial in patients undergoing ureteroscopy. J Urol 2021; 206: 373. Link, Google Scholar 9. : Contemporary trends and end-results of National Institutes of Health grant funding to departments of urology in the United States: a 10-year analysis. J Urol 2021; 206: 427. Link, Google Scholar 10. : The impact of frailty on outcomes of sling surgery with and without prolapse repair. J Urol 2021; 206: 382. Link, Google Scholar 11. : Efficacy of a novel penile traction device in improving penile length and erectile function postprostatectomy: results from a single-center randomized, controlled trial. J Urol 2021; 206: 416. Link, Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue 2August 2021Page: 187-189 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement Advertisement Loading ...

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