This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Jul 2019This 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.0000000000000275AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail A learning curve is frequently discussed for surgeons performing robotic assisted laparoscopic prostatectomy (RALP). Wide variability is reported depending on the outcome of interest and methods of assessment. Bravi et al (page 108) from New York, New York focused on oncologic outcome and, specifically, the incidence of positive margins.1 The relationship between the occurrence of a positive margin and a surgeon’s prior experience was adjusted for tumor stage, grade and prostate specific antigen levels. The overall risk of a positive margin decreased from 16.7% to 9.6% when the procedure was performed by a surgeon with 250 prior operations versus one with 10. For patients with T3 or greater tumors, the percentage of positive margins decreased from 38.4% to 24.9%. Does this mean that a patient should only go to a surgeon who has performed more than 250 RALPs? How does one ever gain that type of experience if recommendations are to only seek high volume surgeons? There have been multiple prior publications in The Journal of Urology® detailing improved results in the hands of high volume surgeons at high volume hospitals. However, it is difficult to assess surgical results in isolation. A surgeon may be able to secure a higher rate of negative margins at the expense of good functional results with continence or potency. The issue, then, becomes complex. There are multiple factors that influence where a patient decides to have surgery, including convenience and accessibility of services. Also, with the many educational opportunities that now exist, learning curve timelines may be reduced. Nonetheless, every surgeon, highly experienced or not, must retain focus on doing what is in the best interest of a patient which, sometimes, may be recommending another surgeon. Partial Versus Radical Nephrectomy with Subsequent Hypertension Propensity score matching was used in this administrative database analysis by Shah et al (page 69) from Rochester, Minnesota to compare the onset of newly diagnosed hypertension in patients undergoing partial vs radical nephrectomy for a renal mass.2 Hazard ratio was 1.4 (p <0.001) for radical nephrectomy and new onset hypertension, in addition to a statistically significant difference in worsening of existing hypertension. These findings were true even in patients with normal preoperative renal function. The authors conclude that potential avoidance of subsequent problems with hypertension is an advantage of partial nephrectomy. Kidney Stones and Narcotic Use Opioids are commonly prescribed for relief of pain associated with nephrolithiasis. However, with the recognition of an opioid addiction crisis, it is prudent to look with scrutiny at prescribing practices. Shoag et al (page 114) from New York and Massachusetts reviewed the records of 23,100 cases in the National Health and Nutrition Examination Survey, and found that current opioid use was significantly greater among those with (10.9%) than those without (6.1%) a history of kidney stones. 3 The rate of current opioid use increased to 13.7% in patients with a history of multiple stones. While prescribing of opioids is appropriate for many patients with renal colic, this study suggests that nephrolithiasis may be a risk factor for long-term use. Optimizing Chemotherapy Sequence for Urothelial Carcinoma and Positive Lymph Nodes Urothelial carcinoma of the upper tract with clinically node positive disease is associated with a poor prognosis, and is most commonly treated with nephroureterectomy and lymph node dissection. In this study of 1,658 patient records in the National Cancer Database by Chakiryan et al (page 76) from Portland Oregon only 6.8% received preoperative chemotherapy but overall survival had improved on multivariable analysis.4 Furthermore, 34.6% of patients who received preoperative chemotherapy had pN0 disease at surgery compared to only 10.3% of those who underwent surgery as initial treatment. These data add to the growing body of literature supporting the use of preoperative chemotherapy for advanced upper tract urothelial cancer. Correlation of Genomic Risk Calculator with Histology of Prostate Cancer Greenland et al (page 90) from San Francisco, California attempt to correlate the genomic prostate score (GPS) generated by the Oncocyte Dx test with the histopathological findings on prostate biopsies.5 Cribriform patterns, especially expansile cribriform, were associated with a higher GPS in patients with Gleason pattern 4 disease. Stromal reaction also correlated with the GPS. The authors suggest that more detailed analysis and reporting of prostate histopathology might provide some of the information that comes from obtaining a GPS. Extended Surveillance Duration for Small Renal Masses Active surveillance of small renal masses is an appropriate but not risk-free strategy for many patients. The primary value of this retrospective study by Whelan et al (page 57) from Canada is the extended followup (median 55 months) and the well characterized patient group.6 A total of 103 patients with a median tumor volume of 2.1 cm and a maximum of up to 4.8 cm were included in the study. Of the cohort 51.5% were alive and free of disease, 45.6% died of other causes and metastatic disease developed in 2 (1.9%), one of whom died of it. The median growth rate was 0.21 cm/year. Surveillance was prescribed in both patients in whom metastatic disease developed because of advanced age, and the renal mass grew to 8 cm in the patient who died of metastasis. This report seems to support the safety of active surveillance for many patients with small renal masses but shows the increasing risk for progression with larger tumors or those with a rapid growth rate. Goal Elicitation Measure to Support Patient Choice of Diversion for Bladder Cancer Patient centered care based on patient preferences and reported outcome measures are increasingly being used to help direct clinical management. Selection of urinary diversion or reconstruction after cystectomy typically is dictated primarily by patient choice. Physicians may think they have adequately explored the relevant topics in discussion with patients but, in reality, may not consider the issues most important to a patient in making such a decision. In a multicenter survey of patients who underwent cystectomy for bladder cancer Leo et al (page 83) tested a 10-item scale to help identify patient goals associated with each diversion technique.7 As may be expected, patients with a neobladder strongly valued maintaining body image and voiding through the urethra but other aspects of patient choice were not as obvious. Further refinement of such tools can help in shared decision interaction. References 1. : The impact of experience on the risk of surgical margins and biochemical recurrence after robot-assisted radical prostatectomy: a learning curve study. J Urol 2019; 202: 108. Link, Google Scholar 2. : Association of partial versus radical nephrectomy with subsequent hypertension risk following renal tumor resection. J Urol 2019; 202: 69. Link, Google Scholar 3. : Kidney stones and risk of narcotic use. J Urol 2019; 202: 114. Link, Google Scholar 4. : Optimizing the sequence of chemotherapy for upper tract urothelial carcinoma with clinically positive regional lymph nodes. J Urol 2019; 202: 76. Link, Google Scholar 5. : Correlation of a commercial genomic risk classifier with histological patterns in prostate cancer. J Urol 2019; 202: 90. Link, Google Scholar 6. : Extended duration of active surveillance of small renal masses: a prospective cohort study. J Urol 2019; 202: 57. Link, Google Scholar 7. : Development of a goal elicitation measure to support choice about urinary diversion by patients with bladder cancer. J Urol 2019; 202: 83. Link, Google Scholar © 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 202Issue 1July 2019Page: 1-2 Advertisement Copyright & Permissions© 2019 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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