This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Jun 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.0000000000000983AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Active surveillance has now become not only an accepted option for many men diagnosed with prostate cancer, but the preferred option. However, surveillance is not a risk-free strategy and 2 articles in this issue of The Journal help define the risk.1,2 Carlsson et al (page 1122) review the records of 2,664 patients with Grade Group 1 cancer, a category considered appropriate by most experts for surveillance.1 Metastatic disease developed in 5 patients during followup and 64% remained treatment-free at 10 years. In the other article in this issue on active surveillance Carlsson et al (page 1117) examine the records of patients with Grade Group 2 cancer, a category for which not all experts think surveillance is appropriate, and treatment-free survival was 49% at 10 years.2 Three men had biochemical recurrence after treatment but none died of prostate cancer, although median followup is still only 3.1 years. It must be emphasized that these patients were followed with a defined protocol that included periodic biopsies and magnetic resonance imaging. These series add to the growing literature on a distinct minority of patients with Grade Group 1 and, it seems, Grade Group 2 cancer who die of prostate cancer during an intermediate followup period. Collagenase Clostridiium Histolyticum for Peyronie’s Disease Collagenase clostridium hystoliticum injections have been shown to decrease penile curvature and improve bother scores in patients with Peyronie’s disease. In this multi-institutional study Goldstein et al (page 1191) combined cases from 3 prior studies to provide 5- year followup data.3 Penile curvature had decreased from 51 to 31 degrees at baseline but an additional 9% improvement was noted up to 5 years after treatment with no further injections. Likewise, bother scores continued to show improvement out to 5 years. No additional treatment related adverse events were observed. Not only does the response to collagenase clostridium hystoliticum seem durable, but further improvement occurs without additional injections. Testosterone Therapy Trends Among Medicare Beneficiaries Zhou et al (page 1184) from Bethesda, Maryland explored the Medicare database and found an annual 15% increase in supplemental testosterone therapy use from 2007 to 2014.4 The most common indication for therapy was hypogonadism (48%) followed by fatigue (18%), erectile dysfunction (15%) and depression (4%). A serum testosterone test in the 120 days preceding introduction of therapy was documented in only 35% of patients. These data cannot be used to calculate the appropriateness of testosterone therapy administration but they do raise concerns. Tumor Seeding after Robot-Assisted Radical Prostatectomy Adenocarcinoma of the prostate is typically a cancer less subject to tumor implantation or seeding compared to, for example, urothelial cancer. In this literature review Motterle et al (page 1141) from Rochester, Minnesota identified 9 cases of port site metastasis and 5 cases of peritoneal carcinomatosis after minimally invasive radical prostatectomy, in addition to 3 cases of each from their hospital.5 Considering the frequency with which this operation is performed, these are still small case numbers. However, these findings do highlight the need to maintain proper oncologic standards to reduce tumor spillage, even for cancers not thought to be prone to implantation. Preoperative Chemotherapy for High Risk Urothelial Carcinoma There is increasing consensus that preoperative chemotherapy should be considered in patients with invasive upper tract urothelial cancer. In this retrospective multicenter analysis of patients who received preoperative chemotherapy by Foerster et al (page 1101) a pathological complete response occurred in 10% and disease was down staged in 45% of patients.6 Those with a pathological response had better overall survival. Association of Circulating Tumor Cells and Prostate Cancer Recurrence The significance of detection of circulating tumor cells after radical prostatectomy remains uncertain. Of 203 patients with an undetectable postoperative prostate specific antigen in this study by Pak et al (page 1128) from Korea 36% had circulating tumor cells detected 4.5 months postoperatively.7 At longer followup biochemical recurrence developed in 81% of cases with versus 48% without circulating tumor cells. These findings raise the possibility that detectable circulating tumor cells may precede biochemical disease progression and possibly identify patients who would benefit from additional treatment. Extraperitoneal vs Transperitoneal Robotic Radical Prostatectomy In this multicenter study Kaouk et al (page 1135) compare the intraperitoneal and extraperitoneal approaches to single port robotic assisted radical prostatectomy.8 Postoperative narcotic use was less and length of stay was shorter with the extraperitoneal approach but it is difficult to know how much these decreases were directly attributable to surgical approach. Positive margins were identified in 26% vs 41% of the cases treated with the intraperitoneal vs extraperitoneal approach, and the 90-day continence rate (60 vs 62% ) was similar. Multiple approaches and modifications in technique have been published but direct comparisons between different series remain difficult. Cancer Specific Outcomes following Early Stage Kidney Cancer Resection Adverse cancer specific outcomes for minimally invasive surgery for some cancers, such as cervical cancer, heighten the awareness for continued scrutiny of outcomes. In this review of the SEER (Surveillance, Epidemiology, and End Results) database Auffenberg et al (page 1094) from New York, New York compared the results of open vs minimally invasive surgery for nonurothelial kidney cancer.9 Neither overall nor cancer specific survival was different on multivariable analysis. Patients undergoing minimally invasive surgery were more likely to receive systemic therapy, although cancer specific reasons for this treatment were not identified. Lead Breakage during Sacral Neuromodulation Lead Removal Breakage of tined sacral neuromodulation devices during removal can result in retained small lead fragments. In a retrospective single institution study by Rueb et al (page 1178) from Cleveland, Ohio leads broke in 35 of 464 patients (7.5%) undergoing removal of an InterStim™ device.10 Leads in the tined region broke in 66% of cases and ghost leads were involved in 81%. Most patients underwent implantation of another device and surgery was performed in 1 patient to remove a lead fragment that was causing pain. Cardiovascular Risk and Prostate Cancer There is still some degree of uncertainty about the significance of cardiovascular complications from androgen deprivation therapy (ADT) in men with prostate cancer. Leong et al (page 1109) from Canada evaluated the profile of patients scheduled to receive ADT and noted that more than two-thirds had a Framingham score consistent with high cardiovascular risk.11 Those at most risk for cardiovascular complications from ADT are patients with baseline risk factors. This study is further evidence that the benefits of treatment must outweigh the risks. For many men with prostate cancer, the widely recognized salutary oncologic effects of ADT make a decision about its use obvious. However, injudicious use can have consequences some of which are significant. References 1. : Long-term outcomes of active surveillance for prostate cancer: the Memorial Sloan Kettering Cancer Center experience. J Urol 2020; 203: 1122. Link, Google Scholar 2. : Risk of metastasis in men with Grade Group 2 prostate cancer managed with active surveillance at a tertiary cancer center. J Urol 2020; 203: 1117. Link, Google Scholar 3. : Long-term safety and curvature deformity characterization in patients previously treated with collagenase clostridium histolyticum for Peyronie’s disease. J Urol 2020; 203: 1191. Link, Google Scholar 4. : Trends and patterns of testosterone therapy among U.S. male Medicare beneficiaries, 1999 to 2014. J Urol 2020; 203: 1184. Link, Google Scholar 5. : Tumor seeding after robot-assisted radical prostatectomy: literature review and experience from a single institution. J Urol 2020; 203: 1141. Link, Google Scholar 6. : Efficacy of preoperative chemotherapy for high risk upper tract urothelial carcinoma. J Urol 2020; 203: 1101. Google Scholar 7. : Association between postoperative detection of circulating tumor cells and recurrence in patients with prostate cancer. J Urol 2020; 203: 1128. Link, Google Scholar 8. : Extraperitoneal versus transperitoneal single port robotic radical prostatectomy: a comparative analysis of perioperative outcomes. J Urol 2020; 203: 1135. Link, Google Scholar 9. : Comparison of cancer specific outcomes following minimally invasive and open surgical resection of early stage kidney cancer from a national cancer registry. J Urol 2020; 203: 1094. Link, Google Scholar 10. : 17-Year single center retrospective review of rate, risk factors and outcomes of lead breakage during sacral neuromodulation lead removal. J Urol 2020; 203: 1178. Link, Google Scholar 11. : Cardiovascular risk in men with prostate cancer: insights from the RADICAL PC study. J Urol 2020; 203: 1109. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue 6June 2020Page: 1033-1034 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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