This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Sep 2020This 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.0000000000001159AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Positron emission tomography/computerized tomography (PET/CT) can detect sites of metastatic disease not visible on other imaging studies but there is still controversy about when the test should be obtained in patients with biochemical recurrence (BCR) after radical prostatectomy. In this issue of The Journal 2 studies help clarify this point. Luiting et al (page 503) from The Netherlands evaluated 419 patients with a detectable prostate specific antigen (PSA) but a value less than 2.0 ng/ml who underwent 68Ga-PSMA-11 PET/CT.1 Overall 42% had demonstrable disease outside the prostatic fossa and PSA at the time of the scan was the strongest predictor. Markowski et al (page 496) from Baltimore, Maryland evaluated the use of 18F-DCFPyL PET/CT.2 No relationship with Gleason sum or PSA doubling time (PSADT) was observed for overall positive imaging but those with a PSA greater than 2.0 ng/ml were less likely to have disease confined to the pelvis. A PSADT of more than 9 months predicated pelvic confined disease. The lower the PSA and the longer the PSADT, the more likely BCR will be associated with pelvic only disease. Conversely, the lower the PSA, the less likely that imaging will be positive. Nonetheless, the sensitivity of imaging in patients with BCR is vastly improved compared to pre-PET/CT times and imaging is playing an increasingly important role in directing therapy for these patients. Patient Reported Outcomes for Predicting Spontaneous Ureteral Stone Passage Patient reported outcomes were used to predict spontaneous passage of ureteral calculi in this retrospective study of 212 patients by McLarty et al (page 524) from Canada.3 Overall 49.5% successfully passed the stone, and stone size and distal ureteral location correlated with spontaneous passage. Of those with spontaneous passage 77% had cessation of pain compared to 44% without. Patient reported stone passage had 59% sensitivity and 87% specificity. On multivariable analysis cessation of pain and reported stone passage were independent predictors of successful stone passage. The authors concluded, though, that both assessments may incorrectly assess stone passage and may not be valid as a sole end point. Current Management of Extraperitoneal Bladder Injuries Twenty level I trauma centers participated in this analysis of bladder trauma management by Anderson et al (page 538).4 Of 323 patients 157 had extraperitoneal bladder injury, 88% had concomitant injury and 79% had a pelvic fracture. Overall 67 patients (43%) had initial repair of the injury in the operating room with the most common indications being severity of injury, injury found during laparotomy or concern for pelvic hardware contamination. The other 57% were managed with catheter drainage and there was no significant difference in complications between the groups. Bladder neck or urethral injuries were the only statistically significant predictors for complications. Competing Risks of Mortality among Men with Biochemical Recurrence after Radical Prostatectomy Biochemical recurrence after surgery for prostate cancer can herald a long clinical course in some patients and competing risks of mortality must be considered. In this multi-institutional study by Daskivich et al (page 511) of 1,225 men with a median followup of 5.6 years after BCR, 20% died of other causes and 6% died of prostate cancer.5 PSA doubling time less than 9 months and high D’Amico risk category were associated with increased risk of prostate cancer mortality. In turn, other cause mortality was higher in men older than 70 years and with any Charlson comorbidity. These findings can help inform decisions about how aggressively to treat patients with BCR. Health Related Quality of Life in Robotic and Open Cystectomy The Randomized Open versus Robotic Cystectomy trial (RAZOR) has yielded important results including comparable oncologic outcomes to date. However, a key factor is health related quality of life between the 2 approaches and Becerra et al (page 450) report those results.6 Physicians often assume that they know what patients think, so patient reported outcomes are essential. Overall, no significant difference was seen in the 2 patient groups. Many surgeons are becoming increasingly confident with robotic cystectomy and less so with an open approach, and patients depend upon their surgeon to recommend what will offer them the best results. Many considerations enter into this assessment but a difference in quality of life does not seem to be among them. High Intensity Focused Ultrasound for Localized Prostate Cancer In this prospective study of focal high intensity focused ultrasound for patients with prostate cancer by Nahar et al (page 483) from Miami, Florida 52 patients had a minimum of 12-month followup.7 Fifteen patients underwent pretreatment transurethral prostate resection or holmium laser enucleation of the prostate for debulking. Overall 83% who had posttreatment biopsies had negative in-field results while de novo out-of-field positive biopsies were found in 13%. Urinary symptoms returned to near baseline within 3 to 6 months and sexual function returned to baseline at 12 months. This adds to the growing body of literature showing good functional results and low complications with focal therapy, but long-term oncologic results are incomplete. Is Partial Nephrectomy Worthwhile for Patients with Severe Chronic Kidney Disease? In patients with chronic kidney disease and a renal mass partial nephrectomy is preferred to radical nephrectomy when feasible. However, preservation of renal parenchyma is futile if the patient has such significant renal disease that progression to renal failure is likely. Aguilar Palacios et al (page 434) from Cleveland, Ohio studied 62 patients with stage IV chronic kidney disease who underwent partial nephrectomy.8 Median time to progression to end stage renal disease (ESRD) was only 27 months and only 14 months when preoperative glomerular filtration rate was less than 20 ml/minute/1.72 m2. African American race predicted progression to ESRD. The authors recommended that renal mass biopsy to detect less aggressive pathology could help improve patient selection and permit active surveillance (AS) when appropriate to avoid rapid progression to ESRD, especially in African American patients. Active Surveillance and Outcomes in Patients Undergoing Delayed Radical Prostatectomy A premise of AS is that appropriate monitoring can permit treatment in a timely manner when there is evidence of disease change. Ahmad et al (page 476) from Canada assessed this by comparing patients with grade group I disease initially managed with AS who eventually underwent surgery with a matched group who had up-front radical prostatectomy.9 Median time on AS was 31 months. There was no difference in the proportion with unfavorable pathological features and the 5-year biochemical recurrence-free survival rate in the initial AS group was 85.8% vs 82.4% for up-front surgery (p=0.38). In this cohort delayed radical prostatectomy was not associated with adverse oncologic outcomes. Sporadic Angiomyolipomas Growth Kinetics While on Everolimus A total of 20 patients with tuberous sclerosis and a renal angiomyolipoma larger than 3 cm were included in this prospective trial of everolimus by Geynisman et al (page 531).10 Overall 55% had a greater than 25% reduction in tumor size at 4 months and 71% at 6 months. Of the patients 20% were withdrawn due to protocol defined toxicities and 40% withdrew due to side effects. Although response was seen in most patients, it is questionable whether the response/side effect profile is sufficient to warrant use in this patient group. Late Recurrences Following Radical Cystectomy Have Distinct Prognostic and Management Considerations Disease usually recurs within 2 years after radical cystectomy for urothelial cancer. Dason et al (page 460) from New York, New York evaluated the characteristics and prognosis of patients with late recurrence.11 A total of 617 patients from a cohort of 2,315 had recurrence and 58 of these had late recurrence (more than 3 years after surgery). Overall 66%, 50% and 33% died within 1 year when recurrence was within 6 months, 2 years or 5 years after surgery, respectively. For those who survived 1 year, the 5-year survival was 21% for those with early recurrence and 45% for late. The authors considered the more prolonged course of patients with late recurrence as an opportunity for metastasectomy in appropriate patients. References 1. : Optimal timing of prostate specific membrane antigen positron emission tomography/computerized tomography for biochemical recurrence after radical prostatectomy. J Urol 2020; 204: 503. Link, Google Scholar 2. : Prostate specific antigen and prostate specific antigen doubling time predict findings on 18F-DCFPyL positron emission tomography/computerized tomography in patients with biochemically recurrent prostate cancer. J Urol 2020; 204: 496. Link, Google Scholar 3. : Patient reported outcomes predicting spontaneous stone passage may not have acceptable accuracy. J Urol 2020; 204: 524. Link, Google Scholar 4. : Current management of extraperitoneal bladder injuries: results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS). J Urol 2020; 204: 538. Link, Google Scholar 5. : Competing risks of mortality among men with biochemical recurrence after radical prostatectomy. J Urol 2020; 204: 511. Link, Google Scholar 6. : Health related quality of life of patients with bladder cancer in the RAZOR trial—a multi-institutional randomized trial comparing robot versus open radical cystectomy. J Urol 2020; 204: 450. Link, Google Scholar 7. : Prospective evaluation of focal high intensity focused ultrasound for localized prostate cancer. J Urol 2020; 204: 483. Link, Google Scholar 8. : Partial nephrectomy for patients with severe chronic kidney disease—is it worthwhile?J Urol 2020; 204: 434. Link, Google Scholar 9. : Does time spent on active surveillance adversely affect the pathological and oncologic outcomes in patients undergoing delayed radical prostatectomy?J Urol 2020; 204: 476. Link, Google Scholar 10. : Sporadic angiomyolipomas growth kinetics while on everolimus: results of a phase II trial. J Urol 2020; 204: 531. Link, Google Scholar 11. : Late recurrences following radical cystectomy have distinct prognostic and management considerations. J Urol 2020; 204: 460. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 3September 2020Page: 403-405 Advertisement Copyright & Permissions© 2020 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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