You have accessJournal of UrologyThis Month in Adult Urology1 Apr 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.0000000000002411AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Risk of Dementia with Androgen Deprivation Therapy The concept that androgen deprivation therapy (ADT) may lead to cognitive dysfunction in men undergoing prostate cancer management has good biological rationale; however, large observational studies have often been inconclusive when describing the effect size of any such association. Lonergan and colleagues (page 832) from San Francisco, California and Ireland queried the CaPSURE registry with a focus on the onset of dementia after primary treatment for prostate cancer.1 Of 13,570 men identified, 317 (2.3%) were diagnosed with a dementia diagnosis after a median of 7 years. After adjusting for key variables, the cumulative use of ADT was significantly associated with dementia. The longer-term followup considered by the authors in this study adds significantly to the literature. The authors propose that these findings are important for clinicians managing men on ADT, and perhaps specifically with today’s treatment intensification, in order that awareness may lead to earlier identification and management of cognitive decline. Active Surveillance in Men with Grade Group 2 Prostate Cancer Consideration of applying the important lessons learned from managing low risk prostate cancer with an active surveillance (AS) stance to men with more favorable Grade Group (GG) 2 disease is an ongoing challenge. Men undoubtedly receive benefit from curative management with GG2 prostate cancer as a whole. However, the conversations informed by experience with more low-grade disease (balancing the side effects of treatment and the natural history of early cancer) are still commonplace for men with favorable GG2 disease and is associated with some equipoise in our treatment recommendations. Waisman Malaret et al (page 805) report outcomes from the Canary PASS cohort, a 10-center prospective active surveillance cohort.2 They reflect on clinical outcomes of 154 patients who enrolled in AS with GG2 prostate cancer as compared to those with GG1 disease, understanding the very different populations that make up these cohorts. They did observe similar 5-year reclassification rates (30% for GG2 vs 37% for GG1), although GG2 cancer was understandably associated with more frequent treatment at 5 years (58% vs 34%) and this was not specifically driven by re-classification only. In men who went on to curative treatment, adverse pathology and early biochemical failure were not significantly disparate for those with GG2 disease. AS for men with GG2 prostate cancer remains a controversy but this collaborative effort from the Canary PASS cohort will continue to provide important information moving forward. Primary Chemoablation of Low-Grade Upper Tract Urothelial Cancer Kidney-sparing approaches are key parts of our armamentarium for patients with upper tract urothelial cancer (UTUC), specifically for smaller, low-grade lesions and those with functionally or anatomically solitary kidneys. However, complete endoscopic ablation can be challenging and adjuvant topical therapies have so far had limited efficacy. In a multicenter study, Matin et al (page 779) report the long-term results following UGN-101 administration, a mitomycin containing reverse thermal gel, for the treatment of low-grade UTUC.3 In the OLYMPUS trial, instillation of UGN-101 was performed in patients via retrograde catheter to the renal pelvis and calyces, with normal urine flow dissolving the gel depot over a period of hours. Complete response was initially observed in a remarkable 58% of treated patients following 6 weekly instillations, and in this longer-term followup that cohort entering a maintenance phase confirms durability of response. From the start of the trial, 23/71 patients (32%) have had no recurrence in the treated kidney. Although future data on long-term side effects such ureteric stenosis and the role of ongoing maintenance instillations are needed, the authors conclude that this durability of response to UGN-101 is clinically meaningful and can offer more kidney-sparing therapeutic alternatives for patients with low-grade UTUC. Randomized Trial of Optilume® Dilation Balloon for Urethral Strictures Endoscopic management of anterior urethral strictures is a common initial strategy that, despite providing fairly immediate relief, is all too often associated with failures requiring more technically challenging urethroplasty. Elliott et al (page 866) from multiple institutions present the results of a randomized, single-blind trial investigating the efficacy of a paclitaxel-coated urethral dilation balloon for recurrent anterior urethral strictures of <3 cm in comparison to our routine endoscopic management.4 These represent the 1-year results of the trial and importantly the team present multiple endpoints that are informative around any definition of success, including both objective parameters and patient-reported outcomes. Anatomical success for the Optilume® balloon device was significantly higher than the control arm at 6 months (76% vs 27%). The durability of symptom relief and freedom from repeat intervention was also significantly higher in the treatment arm. The authors conclude that these results support that the Optilume device is safe and superior to standard endoscopic management of dilation or urethrotomy. The study team should be congratulated for completing this randomized trial and for providing this potential leap forward in the more ubiquitous conservative management of recurrent anterior urethral strictures. Magnetic Resonance Imaging-Directed Biopsy in Active Surveillance Our pantheon of recent work defining the ability for multi-parametric magnetic resonance imaging (MRI) to detect cancerous lesions in the prostate, and target higher-grade lesions to more accurately risk stratify, is increasingly pointing to its utility during active surveillance (AS). Kinnaird and colleagues (page 823) from Los Angeles, California and Bethesda, Maryland advance this notion investigating a cohort of 519 men with low or intermediate-risk prostate cancer who enrolled in 2 prospective studies between 2008 and 2020.5 This current study was designed to determine the upgrading rate when prostate biopsy was guided by MRI at confirmatory biopsy and during AS. Importantly, their primary outcome was upgrading to Grade Group (GG) 3 disease. They find that cancer detected in those with an MRI lesion at confirmatory biopsy increased the risk of subsequent upgrading during AS. In men who upgraded to GG3 during AS, the upgrading was detected by targeted cores only in 27%, systematic cores only in 25% and both in 47%. The authors conclude that when AS begins and follows with MRI-informed biopsies (both targeted and systematic), the upgrading to GG3 is greater when there is a suspicious MRI lesion. These results further emphasize the likelihood that cancer visible on prostate MRI represents a more aggressive phenotype and highlight the increasingly central role of considering MRI findings in our conversations with patients.