This Month in Adult Urology.

Abstract

You have accessJournal of UrologyThis Month in Adult Urology1 Jan 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.0000000000003016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Priapism and Subsequent Cardiovascular Events It has been suggested that underlying vascular dysfunction may predispose men to idiopathic priapism. Mulloy et al (page 253) from Palo Alto, California, and Italy have expanded on this hypothesis in this issue of The Journal of Urology®, demonstrating that men with a history of priapism have an increased risk of thromboembolic events and cardiovascular disease.1 Using a large commercial insurance claims data warehouse, they matched 10,459 patients with a priapism to those with other genital/sexual function diagnoses and demonstrate an increased risk of heart disease and cerebrovascular disease. Further, there appeared to also be a dose-response, with more episodes associated with increasing risk for cardiovascular and cerebrovascular events in the years following a priapism. These findings reinforce the importance for urologists to take a holistic approach in counseling patients presenting with this often debilitating condition. LacdiNAc-Glycosylated-PSA as an Adjunct Test for MRI-detected Prostate Lesions The concept that PSA, and PSA precursor, molecular isoforms may be more cancer-specific is well described and has added incremental benefit in case detection of clinically significant prostate cancer (csPC). In a similar vein, altered PSA glycosylation, a biologically important posttranslational modification, has been demonstrated to also add some specificity. In this issue of The Journal of Urology®, Shoji et al (page 187) from Japan investigate the potential role this biomarker might play in an increasingly common clinical situation.2 The authors evaluated the usefulness of LacdiNAc-glycosylated-PSA (LDN-PSA) for detecting csPC and predicting pathological findings of targeted biopsies for suspicious lesions on multiparametric MRI. In a cohort of 204 patients, LDN-PSA was associated with csPC detection and was particularly useful when the highest PI-RADS (Prostate Imaging–Reporting and Data System) score was 3. The authors conclude that LDN-PSA could be a valuable adjunct, potentially facilitating the avoidance of a biopsy, in the common clinical scenario where a moderately suspicious MRI (PI-RADS 3) is found. Combination Chemo-immunotherapy for Advanced Urothelial Cancer Improving the outcomes of patients with advanced urothelial cancer who are either cisplatin-ineligible or platinum-refractory remains an urgent unmet need. Single-agent pembrolizumab is standard second-line therapy for those who progress after platinum-based chemotherapy and is utilized as first-line therapy for patients who are cisplatin-ineligible. Ongoing combination therapy trials, including chemoimmunotherapy strategies, represent important next steps for these medically complex patients. In this issue, Tsung et al (page 121) from Ann Arbor, Michigan, present a single-arm phase 2 trial of the combination of nab-paclitaxel and pembrolizumab in platinum refractory or cisplatin-ineligible patients with advanced urothelial cancer.3 The observed overall response rate was 50% (18/36), including 3 complete and 15 partial responses. These encouraging results add to the increasing experience with novel combination approaches to systemic therapy for this complicated patient population. Should Perineural Invasion on a Low-risk Prostate Cancer Biopsy Preclude Active Surveillance? Although relatively uncommon, the finding of perineural invasion (PNI) in biopsy specimens that otherwise just harbor Grade Group 1 disease is a conundrum for both pathologists and urologists. In this issue, de la Calle et al (page 180) from Baltimore, Maryland, looked at the clinical significance of PNI in men on active surveillance for Grade Group 1 prostate cancer.4 In this single-institution series, the authors found that having PNI was associated with a higher rate of grade reclassification on subsequent surveillance biopsies. In those who went on to having surgery, there was a link between PNI and extraprostatic extension but, importantly, there was no strong association with adverse pathology or biochemical recurrence. The authors suggest that a finding of PNI in otherwise low-risk disease should not preclude these patients from active surveillance, although they may warrant closer observation. Irreversible Electroporation for Focal Therapy of Prostate Cancer Irreversible electroporation (IRE) is a novel tissue ablation technique in which electrical pulses are delivered to tissue producing necrosis through irreversible cell membrane permeabilization. Theoretical advantages of IRE stem from its action only on the cell membrane and leaving other structures intact. These nonthermal properties could lead to tumor ablation but without damaging the surrounding extracellular matrix, vessels, and nerves, resulting in enhanced safety. Miñana López et al (page 261) from Spain report on their experience with IRE for focal therapy of prostate cancer in this single-center, prospective study.5 Although a relatively small cohort with a median follow-up of 36 months, the oncological results suggest good in-field control of the primary tumor. Importantly, the authors report excellent patient reported outcomes for continence and sexual function, which is integral to the future promise of focal ablative therapies.