This Month in Adult Urology

You have accessJournal of UrologyThis Month in Adult Urology1 Dec 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.0000000000000529AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Most clinicians would consider cystoscopy to be a well tolerated procedure that would cause little patient anxiety or concern. However, survey data from the Bladder Cancer Advocacy Network indicate that research on ways to reduce pain during cystoscopy is considered a top priority by patients. With this in mind, a meta-analysis in this issue of The Journal (page 1136) on reduction of pain during cystoscopy, which initially does not seem too exciting, becomes more relevant.1 Intraurethral lidocaine, especially with a sufficient dwell time, was confirmed to be more effective than plain lubricant. Evidence to support other methods was insufficient. Physicians often assume they know what patients are thinking but patient reported outcomes and needs often do not align with physician perceptions. Patients are telling us, yes, use intraurethral lidocaine but look for other ways to make cystoscopy more tolerable. Importance of Race in Predicting Prostate Cancer Mortality Disparities in prostate cancer outcomes based on race have been demonstrated repeatedly. However, most studies have not been able to distinguish the impact of race vs socioeconomic influences. Hanson et al (page 1209) from Salt Lake City, Utah analyzed 15 variables with separate categories related to tumor characteristics, race and socioeconomics.2 Race was less than 5% as important as tumor characteristics. Furthermore, health care and social factors had a greater or similarly important effect as race across all ages and tumor stages. The authors conclude that addressing disparities in outcome based on race will require attention to health care access and social equality. Cryoablation vs Partial Nephrectomy Mortality Cryoablation for stage T1b kidney cancer has been reported in the literature although it is not recommended by AUA guidelines. In this multicenter, propensity matched study Pecoraro et al (page 1120) compared cryoablation to partial nephrectomy in patients with stage pT1b kidney cancer.3 Cancer specific mortality was 2.5 times higher with cryoablation than partial nephrectomy (p=0.03). The authors recommend that cryotherapy for T1b cancer not be used outside of a specified clinical protocol or trial because of inferior cancer specific results. Association of Smoking and Death from Genitourinary Malignancy The association of smoking and genitourinary cancers is well known but not fully explored in population statistics. Using data from the National Longitudinal Mortality Study of 493,282 cases, Al Hussein Al Awamlh et al (page 1248) from New York, New York evaluated different smoking parameters and bladder, kidney and prostate cancer specific mortalities.4 Of patients who ever smoked 5.6% died within 5 years of followup compared to 3.1% who never smoked (p <0.001). Among those who died of bladder, kidney and prostate cancer, 62%, 58%, and 62%, respectively, were ever smokers. Starting to smoke as a teenager and smoking at home were associated with bladder and kidney cancer mortality while prostate cancer was only associated with daily smoking. Negative Predictive Value of Prostate Magnetic Resonance Imaging Lo et al (page 1159) from Canada studied 502 men with normal multiparametric (mp) magnetic resonance imaging (MRI) and a prior negative prostate biopsy, of whom 96% remained free of clinically significant tumor at a median followup of 6.7 years.5 The overall negative predictive value of mpMRI regardless of whether pre-mpMRI biopsy was performed was 86%, while the positive predictive value was 54%. According to these results, there is a high negative predictive value for normal mpMRI, and the risk of a clinically significant tumor if a prior biopsy was negative is low. Advanced Prostate Cancer and Preexisting Cardiovascular Disease The potential cardiovascular toxicity of androgen deprivation therapy is a subject of clinical importance and ongoing debate. In this phase II randomized trial Margel et al (page 1199) from Israel compared androgen deprivation therapy with a luteinizing hormone-releasing hormone agonist vs antagonist.6 No differences were noted between the groups in the primary outcome, which was endothelial function. However, analysis of the secondary outcome of a cardiovascular event was significantly different as 20% of the patients randomized to the agonist had a major event vs 3% who received the antagonist. Choice of the type of androgen deprivation therapy may make a difference in cardiovascular morbidity especially in patients with preexisting issues. Discharge Disposition after Radical Cystectomy Skeletal muscle and fat mass measured by computerized tomography are readily available indices that have been associated with surgical outcomes. In this retrospective study of patients undergoing radical cystectomy Albersheim et al (page 1143) from Minneapolis, Minnesota found that decreased muscle mass and increased fat were associated with a higher likelihood of a requirement for discharge to a rehabilitation facility.7 This study adds to the growing literature on preoperative features that can predict postoperative problems. Added Value of Concomitant Systematic Prostate Biopsies The added value of systematic biopsies to MRI targeted biopsy has been studied for detection of cancer and clinically significant tumors. Ploussard et al (page 1182) from France assessed grade concordance between biopsy and radical prostatectomy specimens.8 Up grading of radical prostatectomy specimens decreased 22% when systematic biopsy was added to targeted biopsy. Patients with a prostate specific antigen density of less than 20 ng/ml/gm benefitted the most, while systematic biopsy did not modify results in those with pT3-4 tumors or positive nodes. Hemi-Gland Cryoablation for Prostate Cancer Oishi et al (page 1188) from Los Angeles, California evaluated 160 men treated with hemi-gland cryoablation for prostate cancer.9 At a median followup of 40 months 30% had Grade Group 2 or higher cancer on biopsy, while 38% had biochemical recurrence according to Phoenix criteria. Pad-free continence and erections suitable for intercourse were retained by 97% and 73%, respectively, of the patients. Prostate Transition Zone Fibrosis Some men with lower urinary tract symptoms do not respond to medications that target androgen receptor activity or smooth muscle contractility. In a multicenter study Macoska et al (page 1240) analyzed the prevalence of fibrosis in the prostate tissue of men who participated in the Medical Therapy of Prostate Symptoms trial.10 Clinical progression was associated with fibrotic changes in the transition zone. These observations could lead to new treatment strategies for men with lower urinary tract symptoms. References 1. : Reduction of pain during flexible cystoscopy: a systematic review and meta-analysis. J Urol 2019; 202: 1136. Link, Google Scholar 2. : The relative importance of race compared to health care and social factors in predicting prostate cancer mortality: a random forest approach. J Urol 2019; 202: 1209. Link, Google Scholar 3. : Cryoablation predisposes to higher cancer specific mortality relative to partial nephrectomy in patients with nonmetastatic pT1b kidney cancer. J Urol 2019; 202: 1120. Link, Google Scholar 4. : Association of smoking and death from genitourinary malignancies: analysis of the National Longitudinal Mortality Study. J Urol 2019; 202: 1248. Link, Google Scholar 5. : Negative predictive value of prostate multiparametric magnetic resonance imaging among men with negative prostate biopsy and elevated prostate specific antigen: a clinical outcome retrospective cohort study. J Urol 2019; 202: 1159. Link, Google Scholar 6. : Cardiovascular morbidity in a randomized trial comparing GnRH agonist and GnRH antagonist among patients with advanced prostate cancer and preexisting cardiovascular disease. J Urol 2019; 202: 1199. Link, Google Scholar 7. : Skeletal muscle and fat mass indexes predict discharge disposition after radical cystectomy. J Urol 2019; 202: 1143. Link, Google Scholar 8. : Added value of concomitant systematic and fusion targeted biopsies for grade group prediction based on radical prostatectomy final pathology on positive magnetic resonance imaging. J Urol 2019; 202: 1182. Link, Google Scholar 9. : Hemigland cryoablation of localized low, intermediate and high risk prostate cancer: oncologic and functional outcomes at 5 years. J Urol 2019; 202: 1188. Link, Google Scholar 10. : Prostate transition zone fibrosis is associated with clinical progression in the MTOPS study. J Urol 2019; 202: 1240. Link, Google Scholar © 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 202Issue 6December 2019Page: 1069-1070 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 PDF downloadLoading ...

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