This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Feb 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.0000000000000650AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail It is difficult to listen to the radio, watch television or read the newspaper without encountering an advertisement for a testosterone (T) replacement clinic. There are some valid concerns about the consequences of androgen deficiency but it does not account for every malady a man may experience as is often implied in the ads. Lifestyle modifications such as weight loss and exercise can improve T levels but what about dietary changes? Again, any of the media sources listed above commonly tout dietary modification as the answer to most problems. In this issue of The Journal Fantus et al (page 398) explored the association of diet and serum T using the National Health and Nutrition Examination Survey database.1 Multivariable analysis showed that nonrestrictive diets were associated with a higher T level than a low fat diet (p <0.05). However, differences were modest, with overall T levels of 435 ng/dl and 410 ng/dl in the low fat group. Diet may make a small difference but considerations other than impact on T levels should drive decisions about what diet may be best for a man’s health. Number of Ultrasound Fusion Targeted Biopsy Cores Needed to Detect Prostate Cancer There is still debate about whether systematic biopsies of the prostate should accompany targeted biopsies. Furthermore, how many biopsies to targeted regions of interest are required is uncertain. In a cohort of 771 men who underwent radical prostatectomy Leyh-Bannurah et al (page 299) from Germany and Canada found 1,459 tumor suspicious lesions on multiparametric magnetic resonance imaging.2 Prostate cancer detection was made on the first, second, third or fourth core in 79%, 92%, 98% and 100%, respectively. Cancer detection on the first biopsy increased from 67% to 79% to 87% for PI-RADS 3, 4 or 5 lesions. The authors conclude that 3 or more targeted biopsy cores are needed only in a minority of patients. Effect of Extended Pelvic Lymph Node Dissection on Radical Prostatectomy The pendulum continues to swing regarding the therapeutic value of pelvic lymph node dissection (PLND) in association with radical prostatectomy. There seems to be a consensus that node dissection is not indicated (or, maybe, even surgery itself) for low risk tumors but some studies have suggested a salutary impact on oncologic outcomes of PLND in men with intermediate or high risk disease. In this retrospective, multicenter study Preisser et al (page 338) evaluated 9,742 men undergoing radical prostatectomy with or without PLND and matched groups using propensity scoring.3 At 120 months after surgery there was no statistically significant difference in biochemical recurrence rates and metastasis-free or cancer specific survival whether PLND was performed or not. A retrospective study cannot eliminate the possibility of therapeutic value of PLND and there may be merit in the staging information obtained. However, the impact on oncologic outcomes seems to be minimal. Diagnostic Accuracy of Prostate Biopsy and Active Surveillance Cribriform morphology and/or intraductal cancer (IC/IDC) are histological patterns associated with a higher risk of recurrence in patients with prostate cancer. Ericson et al (page 311) from Cleveland, Ohio studied the ability of prostate biopsy to detect these features.4 The sensitivity of biopsy in detecting IC/IDC compared to radical prostatectomy specimens was only 56% but specificity was 87%. Magnetic resonance image targeting did not improve sensitivity. The authors conclude that a biopsy showing IC/IDC is specific enough to permit treatment planning based on that diagnosis but biopsy misses many patients who have IC/IDC. Surgery versus Injection for Primary Stress Urinary Incontinence Women with stress urinary incontinence were randomized to undergo a tension-free vaginal tape (TVT) procedure or injection of a bulking agent in this prospective trial by Itkonen Freitas et al (page 372) from Finland.5 The primary outcome was patient satisfaction and the score at 1 year was 95% for TVT and 59% for injection, which did not meet the noninferiority design for bulking. Perioperative complications occurred in 18% of TVT cases, all of which required reoperations, and 3% of injection cases. Overall, TVT was more successful but with a higher rate of complications, which women must consider when choosing which approach to pursue. Urological Procedures and Antimicrobial Prophylaxis This best practice update from the American Urological Association (page 351) addresses appropriate use of periprocedural antibiotics, a topic of great significance, and should be essential reading for all clinicians.6 The report emphasizes that single dose antibiotic prophylaxis is recommended for most procedures and that prolonged antibiotics typically should be avoided. Risk adjusted recommendations are outlined. Prostate Specific Antigen Monitoring after Laser Enucleation Patients who undergo holmium laser enucleation of the prostate (HoLEP) may still require periodic monitoring for prostate cancer detection. However, what to expect from post-enucleation prostate specific antigen (PSA) values has been uncertain. Abedali et al (page 304) from Indianapolis, Indiana followed 1,147 patients with post-HoLEP PSA data.7 Biopsy in 55 patients revealed cancer in 94% with PSA greater than 1 ng/ml and in 95% with PSA density above 0.1. PSA thresholds for biopsy must be significantly adjusted after HoLEP. Socioeconomic Status and Urge Urinary Incontinence Using data from the National Health and Nutrition Examination Survey, Lee et al (page 379) from Bronx, New York found that 19.4% of participants reported any urge urinary incontinence weekly (4.2%) and daily (1.6%).8 These percentages were higher in patients with lower socioeconomic status even after adjusting for covariates. This is another study highlighting health care disparity based on socioeconomic status but the reasons why are elusive. Focal Therapy for Localized Prostate Cancer The records of 309 patients treated with focal therapy for carcinoma of the prostate were analyzed in this retrospective single institution study by Tourinho-Barbosa et al (page 320) from France.9 Of the patients 190 were treated with high intensity focused ultrasound and 119 underwent cryotherapy. No prostate cancer deaths occurred during the median followup of 45 months and failure-free survival was projected at 54% at 5 years. Preoperative biopsy grade and nadir PSA were associated with treatment failure. One could interpret these results as a glass half full or half empty. Longer followup and additional studies are needed to establish the appropriate role of focal therapy. Percutaneous Tibial Nerve Stimulation for Overactive Bladder Patients at safety net hospitals may face a number of hurdles in accessing and using health care options, many of which are related to socioeconomic considerations, which could potentially impact treatment options offered to such patients. Jiang et al (page 385) from Atlanta, Georgia followed 50 patients treated with tibial nerve stimulation for overactive bladder symptoms.10 Of the patients 80% were black and either uninsured (34%) or subscribed to government insurance (54%). All 12 weekly treatments were completed by 70% of the patients and 86% reported improvement in symptoms. The authors show that treatments that require long-term compliance can be completed successfully in an underserved population and such treatments should be offered as an option to those patients. References 1. : The association between popular diets and serum testosterone among men in the United States. J Urol 2020; 203: 398. Link, Google Scholar 2. : Minimum magnetic resonance imaging-ultrasound fusion targeted biopsy cores needed for prostate cancer detection: multivariable retrospective, lesion based analyses of patients treated with radical prostatectomy. J Urol 2020; 203: 299. Link, Google Scholar 3. : Effect of extended pelvic lymph node dissection on oncologic outcomes in patients with D'Amico intermediate and high risk prostate cancer treated with radical prostatectomy: a multi-institutional study. J Urol 2020; 203: 338. Google Scholar 4. : Diagnostic accuracy of prostate biopsy for detecting cribriform Gleason pattern 4 carcinoma and intraductal carcinoma in paired radical prostatectomy specimens: implications for active surveillance. J Urol 2020; 203: 311. Google Scholar 5. : Tension-free vaginal tape surgery versus polyacrylamide hydrogel injection for primary stress urinary incontinence: a randomized clinical trial. J Urol 2020; 203: 372. Link, Google Scholar 6. : Best practice statement on urologic procedures and antimicrobial prophylaxis. J Urol 2020; 203: 351. Link, Google Scholar 7. : The role of prostate specific antigen monitoring after holmium laser enucleation of the prostate. J Urol 2020; 203: 304. Link, Google Scholar 8. : Associations between socioeconomic status and urge urinary incontinence: an analysis of NHANES 2005 to 2016. J Urol 2020; 203: 379. Link, Google Scholar 9. : Focal therapy for localized prostate cancer with either high intensity focused ultrasound or cryoablation: a single institution experience. J Urol 2020; 203: 320. Link, Google Scholar 10. : Efficacy of percutaneous tibial nerve stimulation for overactive bladder in women and men at a safety net hospital. J Urol 2020; 203: 385. Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue 2February 2020Page: 221-222 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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