Intravesical gentamicin treatment for recurrent urinary tract infections caused by multidrug-resistant bacteria Antimicrobial resistance leads to complications in the management of recurrent urinary tract infections (rUTIs). In some rUTI patients with limited treatment options, intravenous therapy with reserve antibiotics is often required. In this study we aimed to assess the effectiveness, safety, and feasibility of prophylactic treatment with intravesical gentamicin in patients with refractory rUTI caused by multidrug-resistant (MDR) microorganisms.
Non-neuropathic Neuropathic Bladder: Is it Really Non-neuropathic? Hinman Syndrome is a rare disease with urodynamic findings and clinical course that resemble neuropathic bladder and no neuropathic etiology. Diffusion Tensor Imaging (DTI) is a special magnetic resonance imaging (MRI) technique that has recently been used for peripheral nerves but shown to be applicable for evaluation of lumbosacral plexus. Our aim was to evaluate the lumbosacral plexus using DTI, which was not previously performed in Hinman Syndrome.
Editorial Comment It is exciting to see studies such as this one in which elegant technology was applied to improve medical decision making by using presumably more accurate means of prediction. In this case the example is machine learning to predict stone-free status after single session shock wave lithotripsy to treat ureteral stones. If the idea of seeing what machine learning can do for decision making does not excite you, just watch AlphaGo (DeepMind, London, United Kingdom) on Netflix®!
Editorial Comment The authors attempted to develop and validate a decision support model to predict treatment success after a single session of lithotripsy in patients with ureteral stones. They included 15 factors in decision making. While the stone characteristics included in the model, such as stone bulk, density and depth from the skin, have been significant in impacting fragmentation following lithotripsy, renal function, too, is a logical inclusion. However, the impact of patient characteristics like age, gender or body mass index on fragmentation following lithotripsy have been variable.
Reply by Authors It is unfortunate that Gold and Ende have misinterpreted the findings of our study in an attempt to support the integral theory. We believe the integral theory has no scientific validity and consider it a fallacy.
Editorial Comment This rapid review with practice recommendations on the treatment and prevention of recurrent lower urinary tract infections in women is timely as the number of women affected by this condition, especially the older group, is rapidly growing in all of our practices. The authors should be congratulated for their large and detailed search of the best available literature on this topic and for offering a succinct algorithm of the favored alternatives for rUTI prevention and treatment. Notably, a quick glance at reference 3 pointing out the lack of consensus in the definition of rUTIs, and at the quality rating (AMSTAR 2) column in table 3 documenting the “low or critically low” level of evidence in the presented data in 20 of 23 reviews, should be more than sufficient to convince the reader and the international scientific community of the vast gaps in knowledge of rUTIs.
Editorial Comment Recurrent lower urinary tract infections in women are a frustrating problem for patient and provider. Patients suffer with these infectious episodes, often at inconvenient times, and have very bothersome symptoms. Repeat courses of antibiotics put them at risk for yeast vaginitis and gastrointestinal disturbances including C. difficile colitis. These women also suffer from constant worry about when their next infection is going to strike.
Editorial Comment Urinary stone disease is a growing and important public health problem in the United States. Tundo et al report the results of a cross-sectional analysis of data from the 2007 to 2012 NHANES, the gold standard for nationally representative health estimates. Focusing on younger adults, the authors compared the prevalence of self-reported stone disease by gender, finding an equal prevalence of stones (approximately 1/16) among men and women. These findings persisted after controlling for important potential confounders.
Defining Intermediate-Risk Prostate Cancer Suitable for Active Surveillance Active surveillance (AS) for intermediate-risk prostate cancer (PCa) is controversial. Many AS programs are limited to grade group (GG) 1 (Gleason 6) and PSA<10 ng/ml. However, recent guidelines state that AS can be considered for limited GG2 (Gleason 3+4), despite limited data on outcomes. Our objective was to compare prostatectomy outcomes between subgroups of intermediate-risk versus low-risk PCa.
Hypospadias as a Chronic Illness Once a surgical procedure is completed, the duration of followup is determined by the risk of complications. After a routine circumcision one has a single followup and, if all is well, is discharged home. In contrast, penile reconstruction for hypospadias repair has a greater risk of complication development. The general consensus is that the complication rate for distal hypospadias is close to 10%. However, more recent studies have shown that with extended followup proximal repairs have a much more grim outcome.
Editorial Comment Cystinuria represents an aggressive stone disease that is difficult to manage.1 This article indicates that a subsequent noncystine composition develops in 30% of patients, highlighting the importance of repeat analysis with recurrences. This is an interesting finding and brings up points of consideration for the management of cystinuria.
Editorial Comment In this retrospective analysis the authors explored the correlation between pretreatment prostate MRI suspicion scores and post-prostatectomy histological and genotypic risk stratification. The outcomes suggest an association between high risk preoperative MRI (PIRADS 5) and an increased genotype and expression based risk profile as quantified by up-regulation of the molecular pathways associated with tumor progression and castrate resistance. The novelty of the findings is in part captured in figure 4, which demonstrates increased pathway activation and an association with an increasing PIRADS score.
Editorial Comment This is an informative study based on a multi-institutional cross-sectional study of stone formers. It summarizes their health related quality of life as measured by the well-defined WisCOL survey instrument. It included 1,511 patients with some on potassium citrate and/or thiazide diuretics. It provides a good snapshot of these patients at the time of the survey.
This Month in Pediatric Urology Although technical refinements in hypospadias surgery have led to satisfactory functional and cosmetic results in distal hypospadias, surgical outcomes for proximal hypospadias continue to be challenging. Many patients still require multiple procedures throughout life and experience issues associated with a shorter phallus. While surgical outcomes have been the focus of most studies, few studies have been published on the psychological and sexual functional outcomes for adolescents with proximal hypospadias.
Editorial Comment The authors present an interesting study on the long-term functional impact of acute kidney injury after partial nephrectomy. For this purpose the investigators selected a cohort of patients with a solitary kidney who underwent partial nephrectomy. The serum creatinine change following surgery was corrected for the amount of tissue removed, which greatly strengthens the results and conclusions obtained.
Reply by Authors The discovery of the frequently encountered, sporadic, complex renal cyst presents a unique problem. It is important to remember that radiological characterization is dynamic and not a pathological diagnosis. While the Bosniak classification has stood the test of time, it is fraught with interobserver variability and a 50-50 likelihood of malignancy in Bosniak 3 lesions, and it has inadvertently resulted in overzealous repeat radiological imaging.
Editorial Comment When managing renal cysts, conventional teaching suggests that Bosniak 1/2 cysts can be observed while more complex Bosniak 3/4 lesions warrant surgical resection. The current study by Pruthi et al bolsters the argument that this management paradigm is overly simplistic and likely results in overtreatment of many clinically indolent lesions.
Reply by Authors We agree that AUS implantation is a “tricky risky” surgery with a high rate of complications in primary placement and this study looked at reinsertion after previous erosion. As this study shows even high volume surgeons at multiple sites have trouble with this patient group.
Editorial Comment In the United States AUS surgery is done infrequently (6,000 per year) by few urologists (15%), probably because of its high complication rate. These authors analyzed the complications of high volume surgeons following reinsertion after previous erosion.
This Month in Adult Urology A common lament of clinicians is the lack of good biomarkers to predict which men may have clinically significant prostate cancer to better determine those who may benefit from a prostate biopsy. Commercially available tests exist but their use has been restricted in part because of their expense. Two studies in this issue of The Journal specifically explore the cost-effectiveness of some of the available biomarkers and reach similar conclusions.
Editorial Comment In partial nephrectomy for a cystic mass the widely recognized challenge resides in the fact that rupture of the cystic wall might translate into “spillage” of cancerous cells. This is concerning, especially when working in a closed environment (the pneumoperitoneum). The authors performed this intriguing study on those partial nephrectomies in which a cystic renal mass was inadvertently “ruptured.” They reviewed 268 cases done in open or robotic fashion at a total of 8 European institutions and recorded an 18% rupture/effraction/spillage rate, which is nonnegligible.
Editorial Comment The authors report 50 intraoperative CRs in this multi-institutional experience with 268 partial nephrectomies for cystic renal masses. In the patients with CR final pathology revealed malignancy in 38 (77.5%) with Fuhrman grade 2 tumors in 69% and grade 3 or greater tumors in 12%. Although it is disconcerting for the surgeon when CR occurs, it is encouraging that there was no local or systemic recurrence at a median followup of 40 months in the CR group while there was a 2.5% local recurrence rate in the nonCR group.
Editorial Comment Proper information and communication are essential in the process of individualized treatment decision making in men with localized prostate cancer.1,2 The randomized ProtecT trial (Prostate Testing for Cancer and Treatment, ClinicalTrials.gov NCT02044172) did not show any difference in generic anxiety scores among surgery, radiation or monitoring. Using compacted measures the current study confirms favorable long-term anxiety levels in men who are treated expectantly.
Editorial Comment Sonpavde et al report the results of a study evaluating the optimal number of cycles of first line, platinum based chemotherapy in patients with advanced urothelial carcinoma. While trials have been done to investigate the most effective platinum based regimen, there is limited guidance regarding the optimal number of cycles of chemotherapy.1 Based on the results of these trials most patients in clinical practice are treated with the goal of completing 6 or more cycles, a number that was arbitrarily chosen in these trials.
Genomic Prostate Score, PI-RADSv2, and Progression in Men with Prostate Cancer on Active Surveillance OncotypeDx Genomic Prostate Score (GPS) is a 17-gene RNA expression assay intended to help guide treatment decisions for men diagnosed with prostate cancer. The Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2) was developed to standardize the risk stratification of lesions identified on multiparametric prostate MRI. We sought to determine whether these tests are associated with increased risk of biopsy upgrade in men on active surveillance (AS).
Reply by Authors We are familiar with the anatomical dimensions of the prostate since the senior author was the first to describe them in The Journal of Urology in 1993 (reference 13 in article). We find that real-time intraoperative 3-dimensional guided MRI pelvic floor dissection is more valuable than static preoperative studies and better facilitates safe pelvic dissection, whichever type of repair is chosen at initial closure.1 Finally, because ours is a referral center and we have seen more than 25 young patients with loss of the glans, corpora or both with penile disassembly and radical soft tissue mobilization, we avoid these 2 procedures.
Editorial Comment This study offers unique observations on the anatomical dimensions of the prostate and the prostatic, periprostatic, pudendal and penile vasculature using MRI before surgical reconstruction in males with bladder exstrophy compared to normal controls. Awareness of the vascular anatomy in this region is intuitively paramount as any damage to these structures during surgery can cause significant morbidity, eg penile loss during radical soft tissue mobilization.1 Unfortunately the authors did not attempt to correlate the findings on preoperative MRI with the intraoperative findings, treatment choices, modifications of the anatomy postoperatively or outcome of the repair.
Reply by Authors The comment addresses the importance of having patients understand the implications of the choice of whether to leave the vagina intact. In this light we emphasize the value of shared decision making in this field.
Editorial Comment In this series the rate of fistula at the proximal urethral anastomosis (the connection of the native urethra to the urethroplasty portion of the urethra, which is made of tubularized paravaginal flaps) more than doubled from 21% to 48% when simultaneous vaginectomy was not performed. The reasons for this are clear. When the vagina is removed, several more layers can be added to this otherwise delicate urethral suture line. 1) The bulbospongiosus muscle, which in the natal female is splayed out rather than encircling the urethra as in the natal male, can be freed and used to cover the midline urethral suture lines.
Editorial Comment The PICTURE study (references 13 and 14 in article) and the companion PROMIS study (reference 1 in article), in which men being evaluated for prostate cancer underwent magnetic resonance imaging followed by a comprehensive mapping biopsy, are monumental contributions. The biopsy procedure involved transperineal template sampling of the prostate at 5 mm intervals and often more than 60 cores of tissue were obtained at 1 sitting. The work helped establish the value of MRI in men suspected of having prostate cancer.
Editorial Comment In this study a cost-effective analysis was done comparing the performance of TRUSB in all men with elevated PSA and the use of various biomarkers or magnetic resonance imaging first and only performing biopsy if the biomarker was positive. The study modeled biopsy outcomes and likely management strategies. All costs, utilities and other inputs that went into the model were ascertained from the literature.
Reply by Authors Patients in the study group had biopsy proved, high grade UTUC as well as a visible lesion on axial imaging and underwent neoadjuvant chemotherapy followed by RNU. By comparison, patients who had biopsy proved, high grade UTUC but no visible lesion on axial imaging underwent RNU alone. Neoadjuvant chemotherapy was not offered to patients with CIS on ureteroscopic biopsy only. Patients in our study group likely had increased rates of CIS on final surgical pathology because CIS is conventionally unresponsive to chemotherapy, and as a result CIS was the only residual disease in patients who responded effectively to neoadjuvant chemotherapy.
Re: Comparison of Pathological Stage in Patients Treated with and without Neoadjuvant Chemotherapy for High Risk Upper Tract Urothelial Carcinoma Liao et al report outcomes of patients with high risk upper tract urothelial carcinoma (UTUC) treated with or without neoadjuvant chemotherapy. The survival rate of patients with high risk UTUC is poor despite the fact that radical nephroureterectomy (RNU) has been the standard treatment for this condition. The authors suggest that patients treated with neoadjuvant chemotherapy before RNU had a reduction in pathological tumor stage and a decreased prevalence of pT2 or higher disease. Interestingly we noted that the prevalence of Tis was higher in patients who had undergone neoadjuvant chemotherapy than those who had not.
Editorial Comment In this study Kowalik et al found that 50% of women with OAB symptoms reported painful bladder filling and/or painful urgency. These are classic symptoms of IC/BPS (reference 8 in article). Yet a subset of patients with OAB reported bladder pain and comorbid pain conditions similar to IC/BPS.
Editorial Comment Imaging has demonstrated growing usefulness for the detection of prostate cancer. Previous data have shown that MRI fusion biopsy improves the identification of clinically significant prostate cancer and reduces the detection of clinically insignificant cancer compared to standard TRUS guided biopsy.1 In this article Simmons et al found that MRI targeted biopsy diagnosed 81% of cases of clinically significant cancer while reducing the diagnosis of clinically insignificant disease by 40% compared to saturation transperineal template biopsy sampling in men in the PICTURE trial requiring repeat biopsy.
Editorial Comment This report highlights several important aspects of patients with proximal hypospadias. Although these patients represent only a small portion of the overall hypospadias population, they require special care in view of the associated psychosocial and physical challenges outlined in this article. Several challenges face the reconstructive surgeon. These cases may involve an androgen receptor or converting enzyme deficiency, or a significant deficiency in the quality and quantity of penile skin, glans, urethral plate, corpus spongiosum and corporeal bodies.
Editorial Comment Metformin has been proposed to have efficacy in prostate cancer through several putative mechanisms. They include effects on insulin responsive prostate cancers via attenuation of hyperinsulinemia, inhibition of oxidative phosphorylation causing energetic stress in cancer cells and potentially delaying the development of castrate resistant prostate cancer, which hyperinsulinemia can potentiate.1 Retrospective studies have supported the hypothesis that metformin can improve outcomes in patients with prostate cancer (reference 25 in article).
The Kinetics of Sperm Return and Late Failure Following Vasovasostomy or Vasoepididymostomy: A Systematic Review Vasovasostomy (VV) and vasoepididymostomy (VE) are technically challenging microsurgical reconstructive procedures necessary for men with obstructive azoospermia at the level of the vas deferens or epididymis. Patency rates following VV or VE have been widely described in the literature. However, few reports have discussed the timing of sperm return to the ejaculate following reconstruction as well as the proportion of men that develop late failure following VV or VE. Therefore, the objective of this article is to review the rates and predictors associated with late failures and the timing of sperm returning to the ejaculate following VV and VE.
Waiting for Godot: What to Do When a Patient with a Sacral Neuromodulation Device Needs Magnetic Resonance Imaging In this issue of The Journal Guzman-Negron et al (page 1088) address an important clinical concern and present a nice movement from bench to in vivo study.1 The authors previously reported insignificant heating of a full InterStim™ system and a 5 cm lead in a phantom model and significant heating in the presence of an intact lead without an implantable pulse generator.2 This led to a prospective study of a group of patients using the same magnetic resonance imaging (MRI) machine, which showed no significant acute patient harm, clinical deterioration or damage to the implanted devices.
Enhanced Recovery after Surgery Protocols in Pediatric Urology—How are we Doing and What Should we be Doing? Enhanced recovery after surgery (ERAS) protocols have been used for adult colorectal surgery since the late 1990s, with significant evidence supporting improved patient outcomes including reduced hospital stay, lower complication rates, quicker return of bowel function and increased patient satisfaction.1 Since many of the changes have improved quality and outcomes for the patient, and decreased overall hospital costs, the ERAS principles have gained popularity in adult urological cancer surgery.
Editorial Comment In this ex vivo study Hale et al explored MRI/US FBx characteristics that are technical (rigid and elastic registration) and human (experienced and novice users). They measured RE, defined as the distance between fiducial markers reproducing a lesion at MRI and at US.
Editorial Comment The use of MRI defined targets to increase the accuracy of prostate biopsy is of great interest. One of the challenges in the adoption of a MRI guided pathway is identification of the MRI target during a transrectal ultrasound guided biopsy procedure. Hale et al report an assessment of the relative accuracy of software assistance for this using rigid or elastic registration with novice and experienced operators.
Re: Evaluation of the Azoospermic Male: A Committee Opinion K. Hwang, J. F. Smith, R. M. Coward, A. Penzias, K. Bendikson, S. Butts, C. Coutifaris, T. Falcone, G. Fossum, S. Gitlin, C. Gracia, K. Hansen, S. Jindal, A. La Barbera, J. Mersereau, R. Odem, R. Paulson, S. Pfeifer, M. Pisarska, R. Rebar, R. Reindollar, M. Rosen, J. Sandlow, D. Stovall and M. Vernon
This Month in Pediatric Urology In this issue of The Journal is an article about the practical aspects of managing the postoperative care of patients who have undergone a complex reconstructive operation, stressing the importance of approaching these patients in a consistent manner to help increase the likelihood of a smooth recovery. The other article in this issue focuses on a rare condition that afflicts only a few hundred patients but the neurourological manifestations suggest that what may be a confusing array of symptoms are traceable to a common root dysfunction in the pontine region of the brainstem.
Editorial Comment Combined performance of prostate MRI and targeted biopsy has been documented to improve diagnosis and risk stratification over standard of care approaches in recent large-scale studies (reference 4 in article).1,2 While there is growing interest in implementing MRI and targeted biopsy into routine practice,3 it is known that such a successful practice model is associated with a learning curve (references 12 and 13 in article).
Editorial Comment Decision aids should ideally promote clinical equipoise. However, the data from this study suggest some variation to which this is applied, given the differing results on how they altered the pre-exposure intent to undergo or recommend PSA screening. Although there was some change of opinion, a common theme is that the pre-exposure intent was unchanged in the majority of individuals who worked through any of these decision aids. The results are somewhat similar to our experience with testing a decision aid in a randomized controlled trial of a controversial aspect of prostate cancer care.
Editorial Comment Despite the mortality benefit of PSA screening1 and the improved specificity of detecting clinically significant disease with advanced imaging2 prostate cancer screening remains controversial because of the over diagnosis of indolent disease and the treatment related impact on sexual and urinary function. The ultimate goal of any cancer screening DA is to promote preference congruent and well informed screening decisions.3 Weiner et al measured the impact of various DAs on prostate cancer screening preferences in nearly 1,330 participants using a randomized survey.
Editorial Comment The authors incorporated MRI findings and MRI targeted biopsy pathology into established nomograms that are widely used for preoperative prediction of adverse pathological features. Rayn et al suggest that MRI targeted biopsy pathology provides significantly improved prognostication of adverse pathology when added to the Partin (reference 3 in article) and MSKCC (reference 4 in article) nomograms.
This Month in Adult Urology Published articles often refer to accepted treatments as the “gold standard,” typically meaning the treatment to which other approaches must be compared. Economists would scoff at such a phrase since gold reserve backing for currency has long been abandoned. Nonetheless, certain therapies are time tested and commonly accepted. One of these, certainly, is radical cystectomy for muscle invasive urothelial cancer of the bladder.
Reply by Authors Pearce et al are looking for a platform to let the urology community know about their observations regarding long-term use of PPS (Elmiron®) and potential ophthalmological complications, so much so that they have used a letter to the editor concerning our recent article on the FDA BRUDAC (Bone, Reproductive and Urologic Drugs Advisory Committee) criteria for interstitial cystitis/bladder pain syndrome as a pretext. While their letter has nothing at all to do with our article, we are happy that they have a chance to present their observations.
Editorial Comment The clinical significance of radiation exposure from imaging remains an area of debate and the authors provide a fresh perspective. Currently we know that radiation effects are cumulative in nature and yet no dose limit exists related to medical imaging and limited data reflect actual patient radiation exposure from imaging.1 The current study contextualizes these uncertain harms in the backdrop of CTU.
Re: FDA BRUDAC 2018 Criteria for Interstitial Cystitis/Bladder Pain Syndrome Clinical Trials: Future Direction for Research We read this article with interest. As mentioned by the authors, only 2 FDA (U.S. Food and Drug Administration) approved therapies for interstitial cystitis/bladder pain syndrome (IC/BPS) currently exist: oral pentosan polysulfate sodium (PPS) and intravesical dimethyl sulfoxide. We wish to alert readers to a concerning new observation of vision threatening retinal changes associated with long-term exposure to PPS. We recently reported our findings of retinal pigmentary changes in 6 patients undergoing long-term therapy with PPS.
Editorial Comment In this retrospective study the NCDB was used to evaluate practice patterns in patients with SRMs less than 4 cm between 2010 and 2014. Following adjustment the authors report a greater increase in the use of RPN or radical nephrectomy compared to AS. This change was significant even in patients who were 75 years old or older and in those with multiple comorbidities (Charlson comorbidity index 2 or greater).
Predicting Gleason Group Progression for Men on Prostate Cancer Active Surveillance: The Role of a Negative Confirmatory MRI-US Fusion Biopsy Active surveillance (AS) has gained acceptance as an alternative to definitive therapy for many men with prostate cancer (PCa). Confirmatory biopsies to assess the appropriateness of AS are routinely performed and negative biopsies are regarded as a favorable prognostic indicator. Our study sought to determine the prognostic implications of negative multi-parametric magnetic resonance imaging (mpMRI)-transrectal ultrasound (TRUS) guided fusion biopsy (FB) consisting of extended sextant, systematic biopsy (SB) plus mpMRI-guided targeted biopsy of suspicious MRI lesions.
Reply by Author A recent publication in The Journal demonstrated the opposite findings and showed poor quality of life in patients performing intermittent self-dilation.1 Patients experience pain and discomfort, and have difficulty with urethral self-dilation. They are referred or self-refer to a specialist to discuss surgical options to avoid intermittent catheterization. This finding certainly holds true in my reconstructive practice.
Reply by Authors Our report and others suggest that certain patients with muscle invasive bladder cancer can avoid or defer radical cystectomy following a clinically complete response to neoadjuvant platinum based chemotherapy. Although we observed favorable outcomes in this highly select group of patients, there are several limitations and points of caution that must be acknowledged, as the comments highlight.
Editorial Comment In this cohort of patients with rigorous followup these outcomes are favorable. However, 48% of patients experienced recurrence in the bladder, including 11% with MIBC and 37% with high grade nonMIBC. This shortfall in bladder tumor local control is concerning, particularly in this highly selected cohort at centers where there is significant experience with bladder cancer and where hundreds of cystectomies are performed per year. Moreover, these results may not be applicable to the general community.
Editorial Comment As surgeons our job is to intervene where the natural course of disease would lead to worsening illness, suffering and premature death, and observe patients who can be safely surveilled without intervention. Mazza et al present a retrospective series of 148 patients with muscle invasive bladder cancer who elected observation without radical cystectomy after a complete response to neoadjuvant chemotherapy. In a group of carefully selected patients from 2 high volume academic centers treated by 2 experienced surgeons the authors found overall 90% 5-year survival, which is on par with studies of patients who receive NAC with cystectomy.
Re: Moving Beyond an Age-Old Intervention I agree with the author that urethroplasty is the preferred treatment for long or dense strictures. However, most patients have less complex strictures and many prefer a less invasive approach. I have had good results with direct incision or dilation of the stricture followed by a period of intermittent catheterization. Good long-term results are achieved in most patients with this approach, with high patient satisfaction.
Conversion from Cystine to Noncystine Stones: Incidence and Associated Factors Patients with cystinuria are often treated with medical alkalinization and shock wave lithotripsy, although each treatment is hypothesized to increase the risk of calcium phosphate stones. We performed a multicenter retrospective review to evaluate whether stones of another composition develop in patients with cystinuria and with what frequency.
A contemporary analysis of dual inflatable penile prosthesis and artificial urinary sphincters outcomes Inflatable penile prostheses (IPP) and artificial urinary sphincters (AUS) are used to treat men with erectile dysfunction (ED) and stress urinary incontinence (SUI), respectively. After treatment of prostate cancer, men often experience ED and SUI. Dual prosthetic implantation can improve the quality of life of these men. We evaluated the reoperation outcomes in men who underwent dual implantation compared to each individually.
Editorial Comment The authors provide a retrospective review of a large, prospectively managed database of patients with metastatic renal cell carcinoma in South Korea who received a first line tyrosine kinase inhibitor. In this cohort of more than 1,000 patients the authors found that conditional survival improved with time after initial treatment with the tyrosine kinase inhibitor. This trend was mostly driven by patients with Heng poor risk disease.
Re: The Effect of Nerve Sparing Status on Sexual and Urinary Function: 3-Year Results from the CEASAR Study Avulova et al have performed a noteworthy study assessing the true impact of nerve sparing (NS) on the long-term functional outcomes of radical prostatectomy (RP). Walsh et al described the basic technique of NS RP more than 30 years ago.1 A multitude of studies have subsequently displayed functional improvements to potency and urinary continence (UC) with NS vs nonNS RP.2–4 Yet the effect of NS recently has been called into question.5,6
Editorial Comment The authors report the prospective implementation of an ERAS protocol for children undergoing urinary tract reconstruction with small bowel. In this small-scale study 15 patients treated after implementation of an ERAS protocol had shorter time to flatus, stool and discharge home compared to 15 patients treated before implementation. Although adult focused ERAS protocols have been described for various abdominal surgeries,1,2 this study reveals that an ERAS protocol can be successfully used in children despite the variability in physiology, social factors and evidence strength in the 2 populations.
Editorial Comment “Winds of change” blow for prostate cancer diagnostics. Recently published data from the PRECISION (Prostate Evaluation for Clinically Important Disease: Sampling Using Image guidance or Not?) trial clearly emphasize the role of targeted biopsies over systematic biopsies (reference 1 in article). Some are ready to rely on MRI and discard routine systematic biopsies while some are more hesitant and still consider systematic biopsies essential.
Editorial Comment The authors argue against use of the term favorable intermediate risk disease to describe low volume GG2 cancer based on rates of adverse pathology of about 20%, which may not be considered favorable.
Reply by Authors We agree with the comments that there is a clear need for international consensus on hematuria evaluation.1 There remains a lack of consensus on the definition of hematuria. In the United Kingdom the term macroscopic hematuria has been supplanted by visible hematuria as it is easily relatable to patients for whom targeted campaigns to raise awareness of the significance of hematuria are in place.
Editorial Comment This study by Tan et al is a post hoc analysis of 3,556 patients enrolled in the DETECT I prospective multicenter observational study.1 Their goal was to determine whether RBUS could replace CTU for the investigation of patients with microscopic hematuria. The authors found that RBUS can safely replace CTU in patients with microscopic hematuria but CTU should be done to investigate gross hematuria.
Editorial Comment The DETECT I trial is an impressive pragmatic, multicenter, prospective observational trial that seeks to inform current practice regarding the optimal workup of hematuria, which is a common and expensive occurrence. This study adds important evidence to the growing body of literature questioning the usefulness of CTU in the workup of microscopic hematuria as recommended by AUA guidelines (reference 3 in article). Notably guidelines define microscopic hematuria as more than 3 red blood cells per high power field compared to a positive dipstick in DETECT.
Editorial Comment There is no standard of care for biochemical relapse after definitive therapy of prostate cancer. When confronted with treatment options, there are 2 extremes in the patient response, including, “Start ADT to get PSA down under any circumstance” and “Defer ADT for as long as possible.” The former reaction occurs despite education about the long natural history of biochemical relapse without ADT or disease characteristics that support a longer time to metastatic disease, such as longer PSA DT or a Gleason score less than 8.
Impact of Potassium Citrate vs Citric Acid on Urinary Stone Risk in Calcium Phosphate Stone Formers To our knowledge no medication has been shown to be effective for preventing recurrent calcium phosphate urinary stones. Potassium citrate may protect against calcium phosphate stones by enhancing urine citrate excretion and lowering urine calcium but it raises urine pH, which increases calcium phosphate saturation and may negate the beneficial effects. Citric acid can potentially raise urine citrate but not pH and, thus, it may be a useful countermeasure against calcium phosphate stones. We assessed whether these 2 agents could significantly alter urine composition and reduce calcium phosphate saturation.
Editorial Comment This post hoc analysis of the well-known dietary trial of Borghi et al (reference 15 in article) addresses a knowledge gap regarding whether urinary supersaturation indexes predict kidney stone recurrence. It is important to note that in the original study the 24-hour urine parameters dramatically improved after intervention at week 1 and the improvements were generally sustained in the following years.
Reply by Authors For several decades it has been appreciated that multi-agent cisplatin based chemotherapy leads to a pathological complete response in about 30% to 40% of patients with muscle invasive urothelial cancer of the bladder and such a response confers a highly favorable prognosis. Ironically proving that a pathological complete response has occurred requires surgical removal of the bladder and the potential morbidity associated with the procedure.
Editorial Comment Muscle invasive bladder cancer is a challenging disease to treat. Balancing long-term disease control while minimizing short-term and long-term morbidity and maximizing quality of life is difficult when your tools are relatively toxic systemic chemotherapy, radiation therapy and radical cystectomy. Historically the urological community has been slow to consider alternate treatments compared to radical cystectomy as reflected in the relatively low use of neoadjuvant chemotherapy and trimodal therapy.
Editorial Comment In the current NCDB derived study short-term and long-term outcomes after chemotherapy of MIBC were evaluated in patients who did not undergo cystectomy or radiation after bladder tumor TUR. During a 10-year period 1,538 patients underwent chemotherapy alone after TUR while 17,866 underwent cystectomy with or without chemotherapy. The authors noted that patients who did not undergo cystectomy had lower 30 and 90-day mortality rates than those who underwent cystectomy. The noncystectomy group was older, less insured, more likely to be African American, less likely to receive care at an academic facility and most importantly had poorer overall survival than patients who underwent cystectomy.
Editorial Comment Systemic chemotherapy prior to radical cystectomy has been shown to improve survival in MIBC with the best outcomes in patients who achieve a complete pathological response (pT0) (reference 8 in article). The current data from Audenet et al suggest that chemotherapy alone in select patients without cystectomy may result in up to 36% 5-year survival. The implication is that cystectomy can be safely delayed or even eliminated in some individuals with MIBC. However, these results must be interpreted with caution.
Cost-Effectiveness of Urinary Biomarker Panel in Prostate Cancer Risk Assessment SelectMDx (MDxHealth®) is a panel of urinary biomarkers used in conjunction with traditional risk factors to individualize risk prediction for clinically significant prostate cancer. In this study we sought to characterize the effectiveness of SelectMDx in a population of American men with elevated prostate specific antigen.
Symptom Based Clustering of Women in the LURN Observational Cohort Study Women with lower urinary tract symptoms are often diagnosed based on a predefined symptom complex or a predominant symptom. There are many limitations to this paradigm as often patients present with multiple urinary symptoms which do not perfectly fit the preestablished diagnoses. We used cluster analysis to identify novel, symptom based subtypes of women with lower urinary tract symptoms.
The Association of Aspirin Use with Survival Following Radical Cystectomy Aspirin may have antineoplastic properties through the inhibition of inflammatory cytokines that regulate cell proliferation, angiogenesis and apoptosis. In patients with nonmuscle invasive bladder cancer aspirin use has been linked to a reduced risk of recurrence. We evaluated the association of aspirin with survival following radical cystectomy.
Risk of Radiation from Computerized Tomography Urography in the Evaluation of Asymptomatic Microscopic Hematuria The AUA (American Urological Association) guidelines for asymptomatic microscopic hematuria recommend that patients undergo computerized tomography urography, which is associated with high doses of ionizing radiation. To our knowledge the associated risk of secondary malignancy and mortality remains unknown. We modeled the risk of malignancy and associated mortality due to ionizing radiation from computerized tomography urography relative to the additional diagnostic benefit offered over renal ultrasound.
Evaluation of an Aggressive Prostate Biopsy Strategy in Men Younger than 50 Years Longitudinal cohort studies and guidelines demonstrate that prostate specific antigen 1 ng/ml or greater in younger patients confers an increased risk of delayed prostate cancer death. At our institution we have used an aggressive biopsy strategy in younger patients with prostate specific antigen 1 ng/ml or greater. Our objective was to determine the proportion of detected cancer and specifically clinically significant cancer by this strategy.
Editorial Comment Acknowledging the limitations of administrative data sets and the inability to demonstrate causality, this study still highlights several important aspects of acute care for children with nephrolithiasis. First, many children will initially present to nonpediatric hospitals, representing an opportunity and need for engaging adult urology and ED colleagues in the care of these children. In addition, although rates of urological consultation were low, urology consult was associated with decreased rates of ED revisits and use of CT.
Editorial Comment This is an interesting article addressing a not too uncommon scenario in which a patient on required antiplatelet therapy is in need of surgical resection of a suspicious renal mass. While it makes complete sense intuitively that patients on clopidogrel can potentially have more bleeding complications, only 8 patients were on continued clopidogrel therapy. Therefore, some observations have to be viewed with caution. For example, the fact that those patients who remained on clopidogrel had longer operative times could be an incidental finding unless the operative notes dictated state that the increased operative time was due to intraoperative bleeding.
WITHDRAWN: Re: Managing a Pessary Business This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.The full Elsevier Policy on Article Withdrawal can be found at (http://www.elsevier.com/locate/withdrawalpolicy).
Re: Loss of the Urothelial Differentiation Marker FOXA1 is Associated with High Grade, Late Stage Bladder Cancer and Increased Tumor Proliferation Approximately 50% of patients with muscle-invasive bladder cancer (MIBC) develop metastatic disease, which is almost invariably lethal. However, our understanding of pathways that drive aggressive behavior of MIBC is incomplete. Members of the FOXA subfamily of transcription factors are implicated in normal urogenital development and urologic malignancies. FOXA proteins are implicated in normal urothelial differentiation, but their role in bladder cancer is unknown. We examined FOXA expression in commonly used in vitro models of bladder cancer and in human bladder cancer specimens, and used a novel in vivo tissue recombination system to determine the functional significance of FOXA1 expression in bladder cancer.
Information for Authors The Journal of Urology® contains 3 sections: Adult Urology, Pediatric Urology and Urological Survey. Original clinical and translational research studies will be considered for publication in the Adult and Pediatric Urology Sections. Translational research manuscripts must have a clear and proximate translation to patient care, and only preclinical scientific studies that have the direct potential to translate into new and improved standards of care will be reviewed.
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