This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Feb 2023This Month in Adult Urology D. Robert Siemens D. Robert SiemensD. Robert Siemens More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003078AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Trial of Laser Technologies Suggests No Clinical Superiority Advances in laser technology have intimated a promise of superior clinical outcomes in the surgical management of urinary stones. Both the thulium fiber laser (TFL) and the latest high-powered pulse-modulated holmium laser have recently emerged as alternatives for laser lithotripsy, each with its own theoretical advantages. Although previous prospective studies have compared TFL to lower-power holmium laser settings, Haas et al (page 374) from Madison, Wisconsin, report the first randomized study to determine whether the TFL is superior to an advanced pulse-modulated holmium:YAG laser.1 Given some physical properties of TFL, the authors hypothesized that TFL would be associated with faster stone ablation rate. However, the study results were mostly negative, with no differences found in ureteroscope time, laser-on time, and stone-free rates, as well as complications. The authors note that the settings on the TFL were often increased to achieve comparable fragmentation. They conclude that in this randomized trial there was no significant clinical advantage of one laser technology over the other, and provider preference remains a rational approach to technology selection for lithotripsy. Adrenal Androgens and Localized Prostate Cancer Progression The association of androgens and prostate cancer risk or progression is complex. The relative contribution of circulating androgens vs cancer cell de novo synthesis of steroid hormones is likely variable at different stages of disease. Dahmani et al (page 337) from Canada add some intriguing information to this story.2 For the first time they explore the circulating adrenal 11-oxygenated androgen levels and clinical outcomes in patients with prostate cancer receiving radical prostatectomy. In a large cohort of patients with a median follow-up of 94 months, preoperative adrenal 11-oxygenated precursors, potent 11-oxygenated androgens and their metabolites, were assessed. Although in the multivariable analyses no significant association between 11-oxygenated androgens and disease-free survival was observed, the authors do report associations with progression to metastatic disease. Although additional studies are needed, such as more longitudinal analysis and effects of androgen deprivation, these observations are an important step to understand the role of hormones more fully on disease progression of both localized and metastatic castration-sensitive and castration-resistant disease. Adherence to Antibiotic Prophylaxis Guidelines for Cystectomy Antimicrobial stewardship includes a systematic set of actions which promote using antibiotics responsibly in our communities. Clinical guidelines represent an integral tool to help develop these principles in the local context, and measuring adherence can be useful to help identify structural- and process-related barriers to promoting optimal antimicrobial utilization. Barham et al (page 399) in a multicenter study examine the adherence to antibiotic prophylaxis described in the AUA guidelines for patients undergoing radical cystectomy with ileal conduit between 2015-2020 using a large national database.3 Remarkably, they show that for 6,708 patients undergoing cystectomy, only 28% received guideline-concordant prophylaxis with 37% receiving extended duration antibiotics beyond postoperative day 1. In a multivariable analysis adjusting for age and provider characteristics, nonguideline antibiotic prophylaxis was associated with increased odds of infectious events during the original admission. Although residual confounding by unmeasured disease or patient details may explain some of these observations, these data support current AUA guidelines for prophylaxis at cystectomy and ileal conduit, including antimicrobial choice and duration. The authors highlight the need for further outreach to improve ongoing implementation of these guideline recommendations. Bladder Outlet Obstruction After Urethral Sling Surgery Although there appear to be some recent shifts in the frequency of patients with stress urinary incontinence choosing surgical management, mid-urethral slings using synthetic mesh or autologous fascia pubovaginal slings still represent common procedures. Despite their overall success in improving incontinence, de novo urinary symptoms, often associated with bladder outlet obstruction after these procedures, represent an adverse outcome in up to 40% of patients. However, the predictors and consequences of bladder outlet obstruction, as well as the outcomes of sling revision surgery, are not well defined. To help elucidate, Ross et al (page 384) from Canada report on their single-center retrospective review of patients referred with chronic urinary symptoms and a history of urethral sling surgery.4 In a cohort of 105 patients, 60% met their urodynamic definition for obstruction. Fifty-six percent of patients underwent suburethral sling excision, with improvement in storage and voiding symptoms at 6 months of 43% and 87%, respectively. The authors point out that obstruction is common in patients with chronic symptoms after a history of urethral sling surgery and suggest that for those undergoing sling revision, persistent storage symptoms and recurrent incontinence are a common outcome. Effect of Apalutamide on Biopsy Results in Active Surveillance Schweizer et al (page 354) from Seattle, Washington, and San Francisco, California, publish a challenging open-label, single-arm, phase II study investigating the effects of 3 months of apalutamide in men on active surveillance (AS) with low- to intermediate-risk prostate cancer.5 The primary objective of the study was to describe the percentage of patients with a subsequent negative biopsy with the hypothesis that evidence of downstaging on surveillance biopsy might lead to decreased attrition, an ongoing complex consequence for many patients on AS. Of the 22 patients who completed 90 days of apalutamide, 13 (59%) had no evidence of cancer on post-treatment biopsy, and the authors highlight that the short trial of apalutamide was well tolerated with minimal impact on long-term quality-of-life measures. Interestingly, the authors describe favorable pathological effects in those with higher-risk features (ie, grade group 2, high genomic risk). Although these biological observations of a short course of the androgen receptor inhibitor on biopsy results are worthy of highlighting, the goals of this study and others like it deserve careful reflection. Should we as a community pursue future trials aimed at medical interventions to support adherence to AS for patients, many of whom may benefit more from de-intensification? The authors highlight this at length in their discussion, and this is one manuscript that deserves a careful read of these reflections, and accompanying editorials, to facilitate thoughtful discussion beyond the publication of its results. REFERENCES 1. Pulse-modulated holmium:YAG laser vs the thulium fiber laser for renal and ureteral stones: a single-center prospective randomized clinical trial. J Urol. 2023; 209(2):374-383. Link, Google Scholar 2. Preoperative circulating 11-oxygenated androgens are associated with metastasis-free survival in localized prostate cancer. J Urol. 2023; 209(2):337-346. Link, Google Scholar 3. AUA-recommended antibiotic prophylaxis for primary penile implantation results in a higher, not lower, risk for postoperative infection: a multicenter analysis. J Urol. 2023; 209(2):399-409. Link, Google Scholar 4. Prevalence and predictors of bladder outlet obstruction in women with chronic urinary symptoms and a history of urethral sling surgery. J Urol. 2023; 209(2):384-390. Link, Google Scholar 5. Pathological effects of apalutamide in lower-risk prostate cancer: results from a phase II clinical trial. J Urol. 2023; 209(2):354-363. Link, Google Scholar © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue 2February 2023Page: 307-308 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information D. Robert Siemens More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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