This Month in Adult Urology

Abstract

You have accessJournal of UrologyThis Month in Adult Urology1 Jul 2022This 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.0000000000002683AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail A Deep Dive into Nocturnal Polyuria Despite the negative effects on patient’s quality of life and general health, nocturia does not command the public health attention that it rightly deserves. Beyond chronic sleep disturbance, Åkerla et al recently added to the mounting evidence that nocturia may be associated with an increased mortality risk, potentially via its detrimental effects on sleep and other associated comorbidities.1 Nocturia is of course a multifactorial condition that coexists with other lower urinary tract symptoms, although nocturnal polyuria (NP) as the most common causal factor has not been well studied, particularly by sex or gender. In a multi-institutional study, Bosch et al (page 144) present an epidemiological study assessing the prevalence of NP in a nationally representative sample from the U.S. within the Epidemiology of Nocturnal Polyuria survey.2 Beyond the survey they also were able to attain nearly 2,000 3-day bladder diaries. The authors characterize in detail different NP subgroups and bother by gender (women/men), and conclude that these observations may provide insight into management by parsing out issues affecting bladder capacity versus nighttime urine production. Cytoreductive Nephrectomy in the Real World Despite informative prospective, randomized trials examining the role of cytoreductive nephrectomy for patients with metastatic renal cell carcinoma (mRCC) relative to systemic therapy initiation, questions remain about the management of patients with primary mRCC particularly in the era of immune-checkpoint inhibitors. To help clarify, Ghatalia et al (page 71) from Philadelphia, Pennsylvania report on a retrospective comparative analysis of about 1,900 patients with conventional clear cell renal cell carcinoma from multiple centers within the Flatiron Health Database.3 Patients with synchronous mRCC had received systemic therapy alone, or either up-front or deferred cytoreductive nephrectomy. Importantly, several different statistical methods were used to try and control for the inherent selection biases when comparing survival outcomes between these groups. The authors point out that the adjusted overall survival was significantly improved for patients undergoing a cytoreductive nephrectomy regardless of the sequencing with systemic therapy. They conclude that although patient selection is of course key to consider surgery in those with primary mRCC, cytoreductive nephrectomy likely plays an important oncologic role in either the up-front or deferred setting. Prostate Biopsy Techniques and Infectious Complications There has been ongoing debate around the strength of evidence and clinical translation of modifying prostate biopsy techniques to mitigate early complications, specifically serious infections. The growing evidence that transperineal approaches, and perhaps minimizing the number of cores taken, are associated with less infection has only slowly changed practice in some jurisdictions. Adding to this discussion, Tops et al (page 109) from the Netherlands report a large retrospective analysis of post-biopsy infections in nearly 4,000 patients between 2012 and 2019.4 All patients managed at 2 hospitals using very different techniques were included. The results confirm that a transperineal approach is associated with fewer infectious complications than transrectal biopsy with an adjusted odds ratio of 0.29 (95% CI, 0.09–0.73). Interestingly, targeted magnetic resonance imaging (MRI)-based transrectal biopsies with limited cores (approximately 3) were also associated with less infection within 7 days. The authors’ observations further support current trends toward a transperineal approach for prostate biopsies, at least to help mitigate serious post-biopsy infection. First Look at Robot-Assisted Radical Prostatectomy Using a New Surgical Robot The urological world is closely watching the increasing reports of safety and efficacy of new surgical robotic platforms as promising alternatives to the currently available systems. Fan et al (page 119) from China report their single-site experience utilizing the new Chinese robot: KangDuo Surgical Robot-01 system.5 They nicely describe these initial 16 robot-assisted radical prostatectomy procedures performed by 1 surgeon, including the patient cohort and early outcomes as well as surgeon-reported metrics of ergonomics. All procedures were completed without significant intraoperative or postoperative complications. The authors conclude that the system is, therefore, safe and effective, and they should be congratulated in bringing a new robotic system into use for patients with prostate cancer. Cost-Effectiveness of Serial Magnetic Resonance Imaging in Active Surveillance The management of those diagnosed with lower-risk prostate cancer has completely shifted over the last decade, with the role of multiparametric (mp) MRI continuing to expand. Despite real issues with availability and some vagaries in expert interpretation, the promise of an impressive negative-predictive value of mpMRI for significant prostate cancer has helped drive its incorporation into the surveillance armamentarium. But at what cost? Magnani et al (page 80) from Stanford, California provide a thorough cost-effectiveness analysis of mpMRI using a large representative trial sample for the initial model, and a second large and separate active surveillance sample for validation.6 They perform microsimulation of patient trajectories assessing up-front treatment as well as surveillance protocols incorporating routine biopsies or serial mpMRI. The authors show that active surveillance outperformed up-front definitive therapy. On surveillance, the highest expected cost benefit was attained using mpMRI as a triage tool to determine the need for biopsy. Using imaging to guide these decisions resulted in fewer biopsies while still improving cancer outcomes. They conclude that triaging biopsy decisions based on sequential MRI is likely the most cost-effective strategy for those on active surveillance. Mortality following an Initial Negative Prostate Biopsy The recent evolution of mpMRI has unsettled our current toolkit for prostate cancer diagnosis, either de novo or for those patients with a high suspicion of clinically significant disease after a negative transrectal ultrasound (TRUS) biopsy. Although a victory may relate more to its negative predictive value, MRI-informed targeted biopsies will undoubtedly find many high-grade cancers in those with a simultaneous negative systematic biopsy. The burning issue is to understand the ultimate relevance of finding a potentially small amount of Gleason pattern 4 disease, as our current notion is that higher grade (and its volume) is the key biological driver of prostate cancer progression. Kawa et al (page 100) from Denmark add to this discussion, reporting on a Danish national registry analyzing the mortality after an initial negative TRUS biopsy.7 In the cohort of nearly 40,000 men with an initial negative TRUS biopsy, the 15-year prostate cancer-specific mortality was only 1.9%. This risk of course increased with prostate specific antigen, but mortality after re-biopsy (12% were eventually diagnosed with Gleason score ≥7) was unchanged. The authors provocatively conclude that these results raise concerns with routine use of MRI targeting for initial prostate biopsy, and they suggest that MRI targeting should be relegated to men with prostate specific antigen >10 ng/ml after negative biopsy.