You have accessJournal of UrologyThis Month in Adult Urology1 Dec 2020This 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.0000000000001266AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail One of the difficulties in interpreting the medical literature is that apparently well performed studies may have disparate results. Even prospective, randomized trials may disagree, but variability is even more common in retrospective analyses. Many confounders, recognized or not, may be influential. In this issue of The Journal there are 3 studies that evaluate the highly relevant topic of factors that predict progression in patients on active surveillance for prostate cancer. In particular, analysis of whether baseline magnetic resonance imaging (MRI) findings correlate with progression was the subject of 2 articles1,2 and part of the focus of another.3 In a study by Kinnaird et al (page 1180) PI-RADS® (Prostate Imaging Reporting and Data System) category 5 cancer was associated with a 33% chance of progression to Grade Group 3 or greater, which was a statistically significant difference compared to lower categories.1 Deniffel et al (page 1187) found a substantial abnormality in the baseline MRI predicted progression even if the initial biopsy only showed Grade Group 1 disease.2 However, Lonergan et al (page 1216) found that a PI-RADS score of 4 or 5 was not associated with reclassification at any time point.3 Subtle but important differences in the study groups and analyses partially account for the disparate findings. Nonetheless an astute clinician must have a broad understanding and knowledge of published literature and not rely too much on the findings of any single study. Decompression Delay in Obstructive Pyelonephritis That prompt decompression should occur in patients with obstruction and pyelonephritis is not debated. How prompt it is and whether it makes a difference was evaluated by Haas et al (page 1256) from New York, New York using the National Inpatient Sample from 2010 to 2015.4 A total of 311,100 patients were included in the study. A delay of 2 or more days after admission until decompression occurred was associated with a 29% increase in mortality. Delays were more common on weekends and were also related to lower patient income and nonwhite status. These results highlight the need for prompt care and identify socioeconomic and physician availability issues that demand correction. Optimal Number of Targeted Biopsy Cores MRI permits targeting of biopsies for detection of prostate cancer but how many cores should be obtained from targeted sites is unclear. Song et al (page 1202) from China used transperineal (TP) biopsies and included patients with PI-RADS 3 or greater findings on MRI.5 Clinically significant cancer was found in 48%, 54% and 57% by systematic, targeted and targeted plus systematic biopsy, respectively. Three targeted cores seemed to be the optimal number and had a sensitivity of 95% in detecting clinically significant cancers. Lower Urinary Tract Symptoms and Kidney Function Lower urinary tract symptoms (LUTS) are sometimes associated with bladder decompensation leading to upper tract obstruction and renal dysfunction. Routine assessment of renal function in men with LUTS is recommended by some guidelines. This analysis of 5,530 men older than 65 years by Bauer et al (page 1305) from San Francisco, California correlated the presence of LUTS with chronic renal insufficiency.6 Chronic renal insufficiency was identified in 16% of the entire cohort by serum creatinine, 24% by serum cystatin C and 14% with urinary albumin-to-creatinine ratio. However, the presence of LUTS was not a statistically significant variable after adjusting for other factors. Robotic Assisted Retroperitoneal Lymph Node Dissection There is still controversy about whether robotic assisted retroperitoneal lymph node dissection (RPLND) provides oncologic outcomes comparable to open surgery for men with testis cancer. In this study by Hiester et al (page 1242) from Germany, robotic RPLND was specifically assessed in patients with known or suspected metastatic disease.7 Overall 79% of patients had viable tumor on the surgical specimen. With a median followup of 16.5 months 3 patients (11%) had recurrence, all outside of the operative field. The study is not likely to end the debate about robotic RPLND but it does show that satisfactory results can be obtained in selected patients with low volume nodal metastasis. Risk of Metastases in Men on Active Surveillance Many studies have evaluated the risk of reclassification and requirement for treatment in men on active surveillance for prostate cancer. The ultimate determinant of a successful surveillance strategy is to maintain a low risk of metastasis and death from prostate cancer. Maggi et al (page 1222) from San Francisco, California studied 1,450 men with a median followup of 77 months.8 The 7-year prostate cancer specific survival was greater than 99%. However, metastasis developed in 15 men at a median of 62 months after diagnosis, most limited to lymph node disease. With enough time, this may translate into prostate cancer specific mortality. Those with Grade Group 2 disease had an increased risk compared to those with Grade Group 1 tumors. Quality of Surgical Care for Clinically Localized Prostate Cancer The CEASAR (Comparative Effectiveness Analysis of Surgery and Radiation) study enrolled patients with clinically localized prostate cancer diagnosed from 2011 to 2012. Using 6 different quality measures, Reisz et al (page 1236) found no difference in outcomes based on race, age or surgeon volume, unlike many other studies.9 Robotic surgery was more likely to be performed by a high volume surgeon and was associated with fewer complications and better postoperative sexual function. Factors Influencing Prostate Biopsy Pain Transperineal prostate biopsy is being used increasingly because of evidence that infection and sepsis are less common than in biopsy via a transrectal route. The procedure can be more painful for patients, although there are reports of successful in-office TP biopsy. In a multicenter and multinational study by Marra et al (page 1209) of 1,008 men having TP biopsy under local anesthesia, procedural pain was assessed.10 On a 10-point scale the mean pain score with injection of local anesthesia was 3.9 and was 3.1 with performance of the biopsy. Pretreatment anxiety was the strongest predictor of pain. Pregnancy and Delivery after Lower Urinary Tract Reconstruction A history of urinary reconstruction can complicate pregnancy but there are few data on the topic. In this national multicenter study Bey et al (page 1263) evaluated 68 women with 98 deliveries.11 All had undergone prior reconstruction with augmentation cystoplasty, a catheterizable channel and/or artificial urethral sphincter. Of the pregnancies 32% were complicated by a febrile urinary tract infection and 14.6% required upper tract diversion. Elective C-section was performed in 61% of pregnancies but complications were greater during C-sections. The authors concluded that vaginal delivery is preferred in these patients when acceptable from an obstetric standpoint. Risk of Prostate Cancer after Negative Biopsy Repeat prostate biopsy is sometimes indicated even when an initial biopsy showed no cancer. Often, the biopsy is prompted by a change in prostate specific antigen. In this study by Kinnaird et al (page 1180) from Los Angeles, California 733 of 2,716 men had a negative prostate biopsy and 73 of those ended up having another biopsy.1 Overall 23% of repeat biopsies were positive for clinically significant cancer including 54% of those with a PI-RADS 5 lesion on MRI. However, none of the 20 patients with a normal MRI (PI-RADS less than 3) had cancer.