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• W4254347149 abstract "You have accessJournal of UrologyThis Month in Adult Urology1 Jan 2019This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1097/01.ju.0000550099.29951.aeAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Focal therapy for prostate cancer has captured the imagination of patients and clinicians alike. Studies have convincingly shown that morbidity is less than with whole gland therapy which is in line with expectations. Less certain are the oncologic outcomes. It is going to be difficult to gain confidence in this aspect because of the relatively small number of patients included in most cohorts, variable entry criteria for use of focal therapy, differences in followup regimens and the prolonged natural history of the tumor in most patients who may be eligible for this therapy. Information is likely to emerge in snippets, and one such snippet is reported in this issue of The Journal. Focal High Intensity Focused Ultrasound for Intermediate Risk Prostate Cancer Bass et al (page 113) from Canada followed 150 patients for a mean of 24 months after receiving focal high intensity focused ultrasound therapy.1 Followup biopsy in a little more than half of the patients revealed clinically significant cancer (Grade Group 2 or greater) in 42%. Of the patients 81% had not yet required whole gland therapy. Interest in focal therapy will continue to increase, so reports such as this one are valuable. However, we must ask whether this glass is half full or half empty. The answer is partly a matter of interpretation but also a recognition that more information is needed. Robotic Partial Nephrectomy and Size of cT1a Renal Masses In this retrospective, propensity matched study Bertolo et al (page 56) from Italy compared outcomes of robotic partial nephrectomy for renal tumors greater than 2 cm vs 2 cm or less.2 Operative time, blood loss, ischemia time and requirement for blood transfusion were statistically lower in the smaller tumor group. Larger tumors were malignant more often (85.9% vs 74.8%, p=0.002). Tumor location may be an additional important variable. The study showed what one may predict, which is partial nephrectomy for renal masses 2 cm or smaller can be performed with low morbidity. However, many of these tumors may preferably be managed with surveillance or percutaneous ablative procedures. Post-Hospital Syndrome and Penile Prosthesis Outcomes Post-hospital syndrome is the term used to describe a period of increased generalized health risk patients face after an inpatient hospitalization. The global health vulnerability extends to diagnoses unrelated to that for which hospitalization was required. Kirshenbaum et al (page 154) from Maywood, Illinois used public databases to evaluate the records of 16,923 men who underwent implantation of a penile prosthesis.3 Of the patients 477 who had been discharged from a hospital for another condition within 90 days of the prosthesis surgery experienced increased risk of 30-day readmission after surgery, length of stay greater than or equal to 2 days and device complications. Risks decreased progressively with each 30-day increment after the first hospitalization. The authors conclude that delaying an elective procedure such as penile prosthesis beyond the post-hospital syndrome period may improve surgical outcomes. On-Demand Clomipramine for Premature Ejaculation In this prospective study by Choi et al (page 147) from Republic of Korea patients with premature ejaculation were randomized to receive placebo or 15 mg on-demand clomipramine.4 Intravaginal ejaculation latency time was statistically better in those on the active drug and measurement by the premature ejaculation diagnostic tool score also showed superior results for those given clomipramine. Mild to moderate nausea occurred in 15.7% and dizziness in 4.9% of the men. The authors conclude that clomipramine is safe and effective for the treatment of premature ejaculation. Continued 5-Alpha Reductase Inhibitor Use after Prostate Cancer Diagnosis Questions about the effect of 5-alpha reductase inhibitors (5-ARIs) on the risk of developing high grade prostate cancer have diminished with recent studies but some debate remains, which could have important implications for men on active surveillance for a diagnosed cancer. In this analysis of patients participating in the Canary Prostate Active Surveillance Study Kearns et al (page 106) compared patients on a 5-alpha reductase inhibitor to those who had never taken it.5 On multivariable analysis there was no difference in the risk of grade reclassification between the groups nor was there any difference in adverse pathology at prostatectomy between them. Toileting Behaviors of Women Toileting behavior could contribute to bladder related symptoms in women. Kowalik et al (page 129) from Nashville, Tennessee used the results from the patient perception of bladder condition questionnaire completed by 6,695 research participant volunteers to correlate results with self-reported toileting behavior.6 Of the women 99.4% reported sitting to void at home vs only 76.2% when using public toilets. The 53% of participants attributed the bladder problem to convenience voiding, delayed voiding or strained voiding behavior. The authors conclude that behavior based interventions could improve bladder symptoms in some women. Outcomes of Dual Penile Prosthesis and Artificial Urinary Sphincter After radical prostatectomy men may have problems with incontinence and erectile dysfunction, potentially making them candidates for an artificial urinary sphincter as well as an inflatable penile prosthesis. Using the New York Department of Health Statewide Planning and Research Cooperative database, Patel et al (page 141) from New York, New York compared men who received either a sphincter or penile prosthesis separately to those who received both simultaneously.7 Reoperation rates for revision, replacement or removal of the sphincter were not higher in the combined group but the reoperation rate for prosthesis complications were higher 1 and 2 years postoperatively when implantation of both devices was combined in a single operation. Age Predicts Grade Reclassification to Aggressive Prostate Cancer A less aggressive treatment strategy is appropriate for many older men with a diagnosis of low risk prostate cancer. However, some men may harbor a clinically significant cancer. Druskin et al (page 98) from Baltimore, Maryland evaluated a cohort of 1,625 men on active surveillance to determine the influence of patient age on reclassification to a Gleason score of Grade Group 3 or higher cancer.8 The 5-year incidence of reclassification to Grade Group 3 or higher was 4%, 7% and 14% for ages less than 60 years, 60 to 69 years and 70 years or greater, respectively. The impact of age was retained on multivariable analysis. These findings have implications for determining the intensity of followup for older men with low risk prostate cancer. A strategy of active surveillance may be more appropriate for many as opposed to a more relaxed approach of watchful waiting. Predicting Gleason Group Progression for Prostate Cancer Active Surveillance The need for repeat prostate biopsy is a significant impediment for many men considering active surveillance for prostate cancer. There is controversy about whether and how often repeat biopsy is required, and there are different attitudes and approaches in various countries around the world. Bloom et al (page 84) from Bethesda, Maryland compare Gleason Grade Group I or II cancer progression in 60 patients with a negative confirmatory biopsy to 122 patients with a positive confirmatory biopsy.9 Median time to progression to a higher grade group was 74 vs 44 months for negative vs positive biopsies, and the overall risk of grade group progression was lower when the confirmatory biopsy was negative. A negative biopsy is obviously good news but how surveillance strategies should be tailored based on this information is uncertain. References 1. : Oncologic and functional outcomes of partial gland ablation with high intensity focused ultrasound for localized prostate cancer. J Urol 2019; 201: 113. Link, Google Scholar 2. : cT1a renal masses less than 2 versus 2 cm or greater managed by robotic partial nephrectomy: a propensity score matched comparison of perioperative outcomes. J Urol 2019; 201: 56. Link, Google Scholar 3. : Impact of post-hospital syndrome on penile prosthesis outcomes: a period of global health risk. J Urol 2019; 201: 154. Link, Google Scholar 4. : Efficacy and safety of on demand clomipramine for the treatment of premature ejaculation: a multicenter, randomized, double-blind, phase III clinical trial. J Urol 2019; 201: 147. Link, Google Scholar 5. : Continued 5α-reductase inhibitor use after prostate cancer diagnosis and the risk of reclassification and adverse pathological outcomes in the PASS. J Urol 2019; 201: 106. Link, Google Scholar 6. : Toileting behaviors of women—what is healthy?J Urol 2019; 201: 129. Link, Google Scholar 7. : A contemporary analysis of dual inflatable penile prosthesis and artificial urinary sphincter outcomes. J Urol 2019; 201: 141. Link, Google Scholar 8. : Older age predicts biopsy and radical prostatectomy grade reclassification to aggressive prostate cancer in men on active surveillance. J Urol 2019; 201: 98. Link, Google Scholar 9. : Predicting Gleason group progression for men on prostate cancer active surveillance: role of a negative confirmatory magnetic resonance imaging-ultrasound fusion biopsy. J Urol 2019; 201: 84. Link, Google Scholar © 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue 1January 2019Page: 1-2 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. 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