You have accessJournal of UrologyThis Month in Adult Urology1 Jan 2021This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001397AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Medicine and society changed in early 2020. Worldwide shutdowns because of COVID-19 affected life for everyone but had a particular impact on hospitals and patients. The Journal of Urology® chronicled many of the important changes that occurred from use of telemedicine, remote learning and proper allocation of hospital resources. Further, multiple publications in The Journal and elsewhere described methods for appropriate triage of nonCOVID patients and, in particular, performance of nonurgent or emergent surgery. These comments are being prepared months before the publication date for this issue which will be the first of the new year. What further impact COVID-19 or other unanticipated problems will have is very difficult to predict. One hopes, though, that important lessons have been learned. This issue of The Journal features a critical evaluation by Cohn et al (page 241) of scoring systems commonly used for prioritization of elective urological surgery during the pandemic.1 Some methods relied on complex formulas, others consensus expert opinion, and still others used surgeon based scoring. None was validated and all were rapidly put into place. The study shows that the different systems result in substantially different prioritization. A sober analysis of the strengths and weaknesses of each system can help planning for future needs. Early Surgical Intervention for Acute Ureteral Colic There are known criteria for predicting the likelihood of spontaneous passage of a ureteral calculus, including stone size and location. Innes et al (page 152) from Canada used an administrative database in Canada to explore which patients with ureteral calculus benefit from early intervention.2 Of 3,081 patients 1,168 (38%) had early intervention. Patients with stones less than 5 mm in size had more treatment failures with early intervention vs spontaneous passage (31% vs 9.9%) and more emergency department (ED) visits (38% vs 19%). Opposite findings were noted for those with stones 7 mm or larger. Those with stones 5.0 to 6.9 mm in size located in the mid ureter also had fewer failures and ED visits with early intervention. It seems that early intervention when unnecessary can have deleterious effects. Predictors of Colpocleisis Outcomes Dallas et al (page 191) from Los Angeles, California compared the durability and safety of colpocleisis for women with pelvic organ prolapse (POP) to other types of POP repair in a propensity adjusted study using the California Statewide Health Planning data set.3 Reoperation for prolapse was performed in 1.8% of the 2,707 women undergoing colpocleisis. Overall 11% had at least 1 complication and they were severe in 2%. Frailty was the best predictor of complications and morbidity. Colpocleisis provided a more durable repair than other procedures with a failure rate of only 1.8% vs 3.5% for the matched controls. Long-Term Safety with Sling Mesh Implants for Stress Incontinence A total of 36,195 women who had a mid urethral sling for stress urinary incontinence were evaluated by Chughtai et al (page 183) in this New York state database for the years 2008 to 2016.4 At 7 years after surgery the estimated risk of erosion was 3.7% and reoperation was 6.7%. Older patient age and surgery performed at a high volume facility were associated with a lower risk of erosion. There was a higher risk in patients who had previously undergone hysterectomy. Impact of Renal Cancer Surgery Wait Times on Outcomes Using the Canadian Kidney Cancer Information system Shiff et al (page 78) studied 1,769 patients who had surgery for renal cell cancer were studied to determine any impact of wait time on cancer related outcomes.5 The median wait time for the entire cohort was 54 days, but 25% had a wait time of more than 12 but less than 24 weeks from diagnosis to surgery. Wait time inversely correlated with tumor size and directly correlated with Charlson comorbidity index, suggesting prioritization of more concerning tumors and delay for optimization of patients with significant comorbidity. On multivariable analysis longer wait time was not associated with an increased risk of pathological up staging nor with recurrence-free, cancer specific or overall survival. Periprostatic Fat and Early Prostate Cancer Obesity, especially with increased visceral fat, is associated with more aggressive prostate cancer and with progression in men on active surveillance (AS) in some studies. Periprostatic fat volume is measurable on magnetic resonance imaging and may also be associated with prostate cancer aggressive behavior. This study by Gregg et al (page 122) of men on AS measured periprostatic and subcutaneous fat and correlated the findings with the chance of an increase in Gleason grade group on followup.6 Both periprostatic fat volume and linear periprostatic fat measurement were associated with worsened progression-free survival while subcutaneous fat measurement was not. Not all fat depositions seem to have the same implications for men with prostate cancer but in this study the fat closest to the prostate had a measurable impact on progression. Impairment and Recovery Following Cystectomy Patients who require cystectomy for bladder cancer are often older and with significant comorbidity. In this single institution study by Osterman et al (page 94) from Chapel Hill, North Carolina geriatric assessment (GA) was used to compare patients 70 years old or older with those less than 70 years.7 The GA was completed before surgery and at 1, 3 and 12 months after cystectomy. Before surgery 78% had impairment on at least 1 GA measure. At 1 month both groups had worsening physical function with more decline in older patients. However, both groups recovered to baseline at 3 months and maintained that through 12 months of followup. Multiple Negative Surveillance Prostate Biopsies and Active Surveillance The title of this study is provocative in asking the question, “Does cancer vanish or simply hide?” in patients with negative prostate biopsies while on active surveillance. The study by Chu et al (page 109) from San Francisco, California does not really answer the question but it does show that negative biopsies are associated with a good outcome.8 Patients with consecutively negative biopsies had an unadjusted 10-year, treatment-free survival of 84% compared to 74% in those with 1 negative biopsy and 66% when no biopsies were free of cancer. Maybe the cancer is neither hiding nor vanishing—just low volume enough that it isn’t detected on biopsy sampling. Regardless, a negative biopsy is a good thing. Functional Outcomes after Focal and Whole Gland Ablation for Prostate Cancer It makes sense that treatment of only part of the prostate would improve functional results compared to whole gland therapy and that is what Castilho Borges et al (page 129) showed.9 A total of 195 patients treated with high intensity focused ultrasound or cryotherapy as focal therapy (FT) were compared using propensity matching to a group having whole gland treatment. Baseline and followup validated sexual and voiding function questionnaires were obtained. The groups were balanced by propensity matching, and those treated with FT had better sexual function and urinary continence at 3 and 12 months after treatment. The ultimate test of FT will depend upon adequate demonstration of suitable oncologic outcomes. Pelvic Lymph Node Mapping in Penile Cancer Yao et al (page 145) from China performed detailed mapping of the pelvic lymph nodes in patients with penile cancer.10 A median of 18 nodes was removed and pelvic node metastasis was present in 57 of 128 men (44.5%). External iliac nodes were involved in half of the patients and obturator in 36%. Two patients had crossover from one inguinal region to the contralateral pelvic nodes. These findings help establish the boundaries for pelvic node dissection in patients with penile cancer. Active Surveillance for Intermediate Risk Prostate Cancer There is controversy about the role of active surveillance in men with intermediate risk prostate cancer. Agrawal et al (page 115) from New York, New York queried the National Cancer Database to determine temporal trends in the use of AS in this group.11 Overall 176,122 men were identified who were diagnosed with intermediate risk prostate cancer between 2010 and 2016. Of these men 57.3% underwent radical prostatectomy, 36.4% received radiation and 3.2% were followed with AS. The use of AS increased from 1.6% in 2010 to 4.6% in 2016. Both of these numbers are small but reflect increasing acceptance of AS even in men with somewhat higher risk factors. Single Center Experience with Ileal Neobladder The 35-year experience of one of the pioneers in orthotopic bladders substitution, Dr. Richard Hautmann, is presented in this study from Germany (page 174).12 Of 1,598 patients who underwent cystectomy during that time frame 889 (72.5%) had an ileal neobladder and 87% were able to void spontaneously. Daytime continence was achieved in 90% (pad-free 71%) and nocturnal continence was present in 82% (pad-free 47%). Increasing age at the time of surgery was associated with increased risk of incontinence but durable results were achieved with only 12.5% requiring more than 1 pad over 20 years after surgery. The ileal neobladder provides adequate function results for most patients and deterioration in continence over time was not observed.