This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Apr 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.0000000000000734AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Prediction models and nomograms for prostate cancer diagnosis and management have been used for several decades but in years past did not include imaging studies as a meaningful parameter. The emergence of multiparametric (mp) magnetic resonance imaging (MRI) has changed that stance. It is difficult to imagine a contemporary model that does not include mpMRI. Other genomic and biological markers are also being increasingly incorporated. Undoubtedly, continued updates will be required as new parameters are developed. In this issue of The Journal of Urology® incorporation of mpMRI is evaluated with regard to prediction of the presence of clinically significant disease (page 713)1 or pelvic lymph node metastasis (page 719).2 Clinicians and patients often rely on prediction tools to help decide on treatment choices and, therefore, updates that include important variables such as mpMRI are essential. Prostate Specific Antigen Criteria for Diagnosing Therapy Failure Determination of treatment failure after focal therapy of prostate cancer is difficult, particularly with regard to what to expect from prostate specific antigen (PSA) results. Using a prospectively maintained database, Huber et al (page 734) from the United Kingdom report the outcome of high intensity focused ultrasound focal therapy in 598 men with prostate cancer.3 PSA was used to determine when followup biopsies and MRI were indicated. A PSA nadir plus 1.0 ng/ml at 12 months after treatment and nadir plus 1.5 ng/ml at 24 and 36 months had a negative predictive value of 96% for treatment failure defined by a need for any secondary treatment, Gleason grade group 2 or higher in patients who did have a biopsy or clinical disease progression. Most guidelines recommend routine repeat biopsy in patients after focal therapy but the authors suggest that PSA values can be used to select which men require biopsy. Testis Sparing Surgery for Small Testicular Masses Demonstration of a mass within the testis on physical examination or on imaging raises concern for testis cancer and a need for inguinal orchiectomy. However, some intraparenchymal testis masses are benign and amenable to local excision. In this multicenter study Gentile et al (page 760) analyzed 147 cases of planned testis sparing surgery for a small mass.4 In 14% of the cases cancer was identified on frozen section and radical orchiectomy was performed, while in the remaining cases frozen sections were benign and enucleation of the mass was all that was necessary. Lesion size on ultrasound predicted the probability of a benign lesion as the smaller the mass the lower the chance of cancer. Surgery for Post-Prostatectomy Incontinence Incontinence after radical prostatectomy can have a substantial adverse effect on quality of life but it can be corrected with surgical intervention. In this analysis of 29,287 men from the HealthCare Cost and Utilization Project Database for Florida who underwent radical prostatectomy Nelson et al (page 786) from Maywood, Illinois found that only 3.6% subsequently underwent either placement of an artificial urethral sphincter or urethral sling.5 The median time to incontinence surgery was 23.5 months after radical prostatectomy. Whether this indicates underutilization of these procedures is uncertain. Although at least some degree of incontinence occurs in a much larger percentage of patients, many choose to adapt to the leakage and avoid additional surgery. Nonetheless, patients should be made aware that these options exist. Chemotherapy followed by Extirpative Surgery for Urothelial Carcinoma Level I data supporting the use of neoadjuvant chemotherapy for upper tract urothelial carcinoma are lacking. However, neoadjuvant seems preferable to adjuvant therapy considering the renal toxicity of the preferred agents. As part of a prospective phase II trial described by Margulis et al (page 690), 30 patients received accelerated MVAC (methotrexate, vinblastine, adriamycin and cisplatin) chemotherapy before nephroureterectomy, of whom 80% completed a planned 4 cycles of treatment, 14% had a complete response with no residual tumor on a nephroureterectomy specimen and more than 60% had pT1 disease or less.6 No patient had grade 5 toxicity. Absent Diurnal Variation in Serum Testosterone and Testosterone Deficiency Testosterone (T) levels vary according to a diurnal pattern even in young men. Shlykova et al (page 817) from Brookline, Massachusetts studied whether the same diurnal variation occurred in 21 men 18 to 49 years old (mean age 31.7 years) with and without low T by sampling levels throughout the day.7 The highest overall T level was observed at 08:00 while the lowest level occurred at 14:00. Men with a low T failed to demonstrate diurnal variation with 24-hour blood sampling leading the authors to speculate that the same central mechanism may be involved in secondary T deficiency as well as loss of circadian rhythm. Onabotulinum Toxin A for Chronic Scrotal Pain Dockray et al (page 767) from Canada tested the use of onabotulinum toxin A to treat chronic scrotal pain in a randomized, prospective, double-blind trial.8 Patients received either local anesthetic block of the spermatic cord or block plus onabotulinum toxin A. No statistically significant difference was observed for any measured outcome. Interestingly, 69% of men reported an improved visual analog pain score on an open label extension, suggesting a substantial placebo effect. Active Surveillance for African American Men with Prostate Cancer Debate remains as to whether African American men with prostate cancer are suitable candidates for active surveillance. Schenk et al (page 727) compared 89 African American men participating in the Canary Prostate Cancer Active Surveillance Study to other participants, and found that the rate of treatment between the groups was similar.9 African American race was not associated with a higher risk of reclassification on protocol biopsies or adverse pathology when radical prostatectomy was performed. The authors conclude that favorable risk cancers in African American men can be managed with active surveillance. Late Luteinizing Hormone Releasing Hormone Agonist Dosing and Testosterone Suppression Testosterone suppression by luteinizing hormone releasing hormone analogs depends on timely administration of followup injections. In this multi-institutional study Crawford et al (page 743) evaluated the frequency and consequences of delayed analog injections in 22,860 men with prostate cancer.10 Of the patients 84% received a delayed injection compared to other participants in the pivotal trials. Mean T levels were higher when injections were late. Insurance companies frequently deny coverage for early administration but this study points out that attention should be paid to making certain that undue delays do not occur as elevations in T beyond the castrate range may result. References 1. : Development and external validation of a multiparametric magnetic resonance imaging and International Society of Urological Pathology based add-on prediction tool to identify prostate cancer candidates for pelvic lymph node dissection. J Urol 2020; 203: 713. Link, Google Scholar 2. : External validation and comparison of prostate cancer risk calculators incorporating multiparametric magnetic resonance imaging for prediction of clinically significant prostate cancer. J Urol 2020; 203: 719. Link, Google Scholar 3. : Prostate specific antigen criteria to diagnose failure of cancer control following focal therapy of nonmetastatic prostate cancer using high intensity focused ultrasound. J Urol 2020; 203: 734. Link, Google Scholar 4. : Testis sparing surgery of small testicular masses: retrospective analysis of a multicenter cohort. J Urol 2020; 203: 760. Link, Google Scholar 5. : Use of surgery for post-prostatectomy incontinence. J Urol 2020; 203: 786. Link, Google Scholar 6. : Phase II trial of neoadjuvant systemic chemotherapy followed by extirpative surgery in patients with high grade upper tract urothelial carcinoma. J Urol 2020; 203: 690. Link, Google Scholar 7. : Absent diurnal variation in serum testosterone in young men with testosterone deficiency. J Urol 2020; 203: 817. Link, Google Scholar 8. : A randomized, double-blind, controlled trial shows that onabotulinum toxin A nerve blocks do not provide improved pain control in men with chronic scrotal pain. J Urol 2020; 203: 767. Link, Google Scholar 9. : African American race is not associated with risk of reclassification during active surveillance: results from the Canary Prostate Cancer Active Surveillance Study. J Urol 2020; 203: 727. Link, Google Scholar 10. : The impact of late luteinizing hormone–releasing hormone agonist dosing on testosterone suppression in patients with prostate cancer: an analysis of United States clinical data. J Urol 2020; 203: 743. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue 4April 2020Page: 635-636 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 PDF downloadLoading ...

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