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• W4235328051 abstract "You have accessJournal of UrologyThis Month in Adult Urology1 Aug 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.0000000000001097AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail As in many aspects of medicine, improved imaging has changed the landscape of cancer management. Positron emission tomography (PET) scans once lacked sensitivity and specificity sufficient for the test to be clinically useful. Newer tracers are changing that and 2 articles in this issue of The Journal analyze PET imaging in urological cancers. Imaging and Tumor Burden Underestimation in Nodal Recurrence of Prostate Cancer In a multi-institutional study Fossati et al (page 296) compared 68Ga-PSMA (prostate specific membrane antigen) and 11C-choline PET for detecting nodal disease in patients scheduled for salvage lymph node dissection.168Ga-PSMA performed better in patients with a prostate specific antigen (PSA) less than 1.5 ng/ml but both tracers significantly underestimated the burden of disease by missing nodes that were histologically involved with cancer. Positron Emission Tomography-Computerized Tomography before Radical Cystectomy Dason et all (page 254) from New York, New York and Columbus, Ohio evaluated the diagnostic performance of 18F-fluorodeoxyglucose PET/computerized tomography (CT) for detecting nodal disease before radical cystectomy for muscle invasive bladder cancer.2 The sensitivity was only 7% to 23% without nodal enlargement on CT. The sensitivity was improved in patients with clinically positive nodes (enlargement on CT). Taken together, these studies help define the clinical role of PET for nodal staging of prostate and bladder cancer. Trade-offs between Risks and Benefits of Prostate Cancer Treatment Pursuit of treatment that can favorably affect cancer specific survival vs the potential for quality of life compromises is a conundrum that faces many men with localized prostate cancer. Historically clinicians have assumed that they know what a patient may want and patients themselves have been reluctant to express their own opinions. That has largely and, for the better, changed. Shared decision making is commonly in use but how the majority of patients assess these trade-offs is under studied. Watson et al (page 273) from the United Kingdom used a discrete choice experiment to understand treatment choices of patients from 34 institutions.3 Those with low to intermediate risk cancer were willing to trade a 6.99% decrease in survival for the benefits of active surveillance. Patients of all risk groups were willing to trade off some cancer specific survival for improved quality of life. There can obviously be considerable variation among patients as they weigh quantity vs quality of life. The role of the physician is not to make this choice for the patient but to help guide him through the decision process. A Missing Link in the Female Urinary Microbiota There is increasing interest in understanding the microbiome of the urinary tract and using that knowledge to investigate disease and dysfunction. Chen et al (page 303) from Maywood, Illinois used mass spectroscopy to study urine samples and swabs from different portions of the female lower urinary tract.4 Urethral and periurethral microbiota were similar to one another. Urethral microbiota were dissimilar to that of voided urine. Age, menopausal status and sexual activity all influenced results. Higher Percent Free Prostate Specific Antigen and Poorer Outcomes The percentage of total PSA in a free form can help diagnose prostate cancer in patients with a total PSA of 4 to 10 ng/ml. Overall, a low ratio is associated with a higher risk of prostate cancer. Calculation of a percent free ratio is not generally part of the management algorithm for a detectable PSA after radical prostatectomy. Woon et al (page 289) from Canada evaluated the predictive value of %PSA in men with biochemical recurrence after surgery.5 They identified what appears to be a paradoxical finding of a worse prognosis for a high ratio, greater than 15%. This is a provocative and not completely explained finding that warrants additional study. Clinical Benefit of 5-Alpha Reductase Inhibitors for Benign Prostatic Hyperplasia Using health care and pharmacy claims from a large database, Zhang et al (page 325) from Boston, Massachusetts studied real-world adherence to treatment with 5-alpha reductase inhibitors for symptoms of benign prostatic hyperplasia.6 Overall 74.9% of patients had high medication adherence during the first year of treatment. Patients with low adherence were more likely to undergo surgical intervention. These figures show greater adherence to treatment with 5-alpha reductase inhibitors than some other studies. Rare Variants of Prostate Adenocarcinoma The National Cancer Database was queried by Bronkema et al (page 260) from Detroit, Michigan for men with prostate adenocarcinoma to determine the frequency and impact of histological variants.7 Of 1,345,618 men only 0.38% presented with rare variant cancers, including mucinous, ductal, signet ring, adenosquamous, sarcomatoid and neuroendocrine. All variants presented with higher clinical stage than nonvariant tumors. Metastatic disease was most common with neuroendocrine (62%). On multivariable analysis ductal, signet ring, neuroendocrine, sarcomatoid and adenosquamous were all associated with higher mortality. Predictors of Presentation to Emergency Department in Urinary Retention The characteristics of patients who present to the emergency department (ED) with acute urinary retention were studied by Patel et al (page 332) from Chicago, Illinois using the State Emergency Department Databases.8 The mean age for males presenting with acute urinary retention was 72.2 years. African American or Hispanic race was associated with an increased likelihood of ED treatment. This suggests the possibility that these patients are under treated in the outpatient setting and must rely upon the ED. Tumor Location of Latent and Incidental Prostate Cancer Some studies have shown differences between Asian and Western men in tumor location and frequency for prostate cancer detected incidentally. In this contemporary analysis Inaba et al (page 267) from Japan compared Japanese patients autopsied for an unrelated cause of death and those undergoing cystoprostatectomy for bladder cancer.9 Prostate cancer was discovered in 39% of autopsy specimens and 31.6% of cystoprostatectomy cases. Overall 39% of the entire group had transition zone cancers and in elderly men peripheral zone cancers were more frequent. Women's Toilet Behaviors, Bladder Symptoms and Public Restroom Use Who wants to use a public restroom? This is even more of an issue for women, and in this unique study Reynolds et al (page 310) from Nashville, Tennessee assessed attitudes and behavior of women toward public restrooms and lower urinary tract symptoms (LUTS).10 Of 6,004 women in the study 26% limited public restroom use most or all of the time. They also reported using a nonsitting position more frequently and holding urine intentionally to avoid use. Women who regularly limited public restroom use more frequently reported LUTS. Whether this is because unhealthy toilet habits precipitated LUTS or because LUTS heightened concerns about public toilet use is unclear. References 1. : Underestimation of positron emission tomography/computerized tomography in assessing tumor burden in prostate cancer nodal recurrence: head-to-head comparison of 68Ga-PSMA and 11C-choline in a large, multi-institutional series of extended salvage lymph node dissections. J Urol 2020; 204: 296. Link, Google Scholar 2. : Utility of routine preoperative 18F-fluorodeoxyglucose positron emission tomography/computerized tomography in identifying pathological lymph node metastases at radical cystectomy. J Urol 2020; 204: 254. Google Scholar 3. : Evaluating the trade-offs men with localized prostate cancer make between the risks and benefits of treatments: the COMPARE study. J Urol 2020; 204: 273. Link, Google Scholar 4. : The urethral microbiota: a missing link in the female urinary microbiota. J Urol 2020; 204: 303. Link, Google Scholar 5. : A high percent free prostate specific antigen in the setting of biochemical recurrence after radical prostatectomy is associated with poorer outcomes: a validation study using prospectively collected biobank specimens. J Urol 2020; 204: 289. Link, Google Scholar 6. : High real-world medication adherence and durable clinical benefit in Medicare patients treated with 5-alpha reductase inhibitors for benign prostatic hyperplasia. J Urol 2020; 204: 325. Link, Google Scholar 7. : Rare histological variants of prostate adenocarcinoma: a National Cancer Database analysis. J Urol 2020; 204: 260. Google Scholar 8. : Disparities in benign prostatic hyperplasia progression: predictors of presentation to the emergency department in urinary retention. J Urol 2020; 204: 332. Link, Google Scholar 9. : Tumor location and pathological features of latent and incidental prostate cancer in contemporary Japanese men. J Urol 2020; 204: 267. Link, Google Scholar 10. : Women's perceptions of public restrooms and the relationships with toileting behaviors and bladder symptoms: a cross-sectional study. J Urol 2020; 204: 310. Link, Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 204Issue 2August 2020Page: 203-204 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement Advertisement Loading ..." @default.
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