You have accessJournal of UrologyThis Month in Adult Urology1 Mar 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.0000000000003128AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Randomized Controlled Trial for Adolescent Varicocele The goals of repairing a significant adolescent varicocele, alleviation of symptoms, reversing testicular hypotrophy, and potentially improving semen parameters and future paternity have been attained after several different procedural approaches. In this issue of The Journal, Chung et al (page 600) from Hong Kong present the first randomized prospective trial comparing sclerotherapy to laparoscopic spermatic vein ligation for adolescent varicocele.1 The authors are to be commended for completing this randomized surgical trial with outcomes focused on recurrence, testicular catch-up growth, and complications. After randomizing 133 patients, the authors show that recurrence after sclerotherapy was noninferior to laparoscopic ligation, with remarkably high success rates, and provide data to justify longer-term testis volume assessment after varicocele repair. Although microscopic subinguinal varicocelectomy was not assessed, the authors conclude that sclerotherapy has similar efficacy with less hydrocele formation compared to a surgical approach. Depth of Prostate-specific Antigen Decline Predicts Outcomes in Men With Nonmetastatic Castration-resistant Prostate Cancer Although clinical progression events and survival outcomes are key to assessing novel therapies for advanced prostate cancer, PSA dynamics can be a useful surrogate and are central to our discussions with patients and their families in clinic. Hussain et al (page 532) from multiple institutions report on this relationship between PSA dynamics and survival outcomes in men enrolled in the PROSPER study evaluating enzalutamide for nonmetastatic castration-resistant prostate cancer.2 The authors describe a clear message for clinicians managing patients with this novel hormonal therapy in that a greater depth of PSA decline is associated with improved outcomes, including overall survival. Although these observations are post hoc in nature, they seem to validate PSA response as a prognostic factor and have important implications for patient counseling, follow-up, and future novel therapy study design. Conservative Management of High-grade Renal Trauma The evolution of renal trauma classification has led to better communication between care teams and improved prognostication of outcomes, allowing some refinement of management strategies. Although conservative management is accepted as our first stance for lower-grade trauma, there is scant evidence to point towards the role of nonoperative approaches for the more severe grade V injuries. Hakam et al (page 565) from San Francisco, California, hypothesized that there may be certain populations of patients with more severe trauma that have some favorable clinical parameters making them potential candidates for nonoperative management. They queried a large hospital-based trauma registry of 1,474 patients that survived to discharge and observed that 38% were managed nonoperatively. Although the data set is not detailed enough to understand all the subtleties that go into the decision-making to bring a patient to the operating room, stable vitals and nonpenetrative injury were associated with conservative approaches. The authors provide evidence that not all grade V injuries are the same, and that nonoperative management is possible in some patients. The authors conclude that even though operative intervention and angioembolization remain common with these injuries, further research is needed to identify specific radiological and clinical characteristics that may define suitable cases for nonoperative approaches. Cancer Outcomes of Active Surveillance in the Real World Although oncologic outcomes of active surveillance (AS) for men with lower-risk prostate cancer from institutional series have been promising, they generally report on highly selected cohorts with stringent follow-up. Long-term outcomes from AS cohorts at the population level, representing more real-life data, are limited. Timilshina et al (page 540) from Canada describe a retrospective, population-based study to assess the oncologic outcomes of 21,282 men with Grade Group 1 disease managed with AS or initial treatment.4 At 10 years, 39% remained on AS, and on multivariable analysis, AS had a statistically significant worse metastases-free survival and prostate cancer–specific mortality compared to initial treatment. The authors concluded that AS was associated with slightly worse long-term outcomes but advise that the harms of overtreatment should be weighed against the small absolute differences observed in 10-year cancer-specific survival (1%). This well-described and analyzed cohort represents men diagnosed between 2002-2014. It is reasonable to consider that the expansion of more contemporary strategies to risk stratify and follow men with lower-risk cancer would further minimize any compromise in oncologic outcomes for AS. Blood Transfusions Lead to Postoperative Venous Thromboembolism After Cystectomy Radical cystectomy is a morbid surgery and a significant contributor to early postoperative complications is venous thromboembolism (VTE). Efforts to identify those at highest risk and examine mitigation strategies to decrease the rates of VTE are important quality initiatives for these patients. Perioperative red blood cell transfusion has been associated with several adverse events, but the potential influence of transfusion on VTE development remains underexplored. These concepts are further examined in a large institutional experience reported by Myers et al (page 525) from Jacksonville, Florida, and Rochester, Minnesota, describing the rates of VTE at 90 days based on whether no transfusion was given compared to postoperative transfusion alone, or intraoperative with or without postoperative transfusion.5 In this large cohort of 3,755 patients, 4.3% experienced a VTE and 56% received a blood transfusion. Taking into account important patient and cancer characteristics, intraoperative with or without postoperative blood transfusion was associated with an increased risk of VTE. For each unit of blood transfused there was 7% higher odds of VTE, so the authors underscore that ongoing efforts to limit transfusion in patients undergoing cystectomy are warranted.