Journal of Urology ( White Journal) In Press
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The study by Routh et al (page 000) in this issue of The Journal is state-of-the-art health services research, with impressive and sophisticated statistical analyses to determine whether participant centers in the National Spina Bifida Patient Registry (NSBPR) vary in their rates of bladder reconstruction.1 They determined that bladder reconstruction rates do indeed vary, and are associated with a variety of disease related and nondisease related factors.
Artificial urinary sphincter in male patients with spina bifida: Comparison of perioperative and functional outcomes between bulbar urethra and bladder neck cuff placement
To evaluate the perioperative and long-term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter (AUS) in a population of adult male patients with spinal dysraphism.
Biologic behavior and long-term outcomes of carcinoma in situ in upper urinary tract managed by radical nephroureterectomy
Carcinoma in situ (CIS) in urothelial carcinoma generally has poor prognosis, but the outcomes of pure/primary CIS tumor (p-CIS) and the behavior of concomitant CIS (c-CIS) with pTa-pT4 upper tract urothelial carcinoma (UTUC) managed by nephroureterectomy has not been specified. The aim of our study was to explore the biological and prognostic features of c-CIS, compared with p-CIS.
Vesicoureteral reflux remains an incompletely understood condition with its diagnosis and subsequent management becoming increasingly controversial since the publication of the AAP revised practice parameters in 2011 (reference 2 in article). Garcia-Roig et al demonstrated a significant national decline in voiding cystourethrogram encounters and antireflux procedures following guideline implementation, consistent with other recent reports.1 These studies provide important data regarding the diagnosis and surgical correction of reflux, and perhaps highlight a step forward in limiting the overtreatment of a common condition.
Intra-Trigonal Onabotulinum Toxin A improves bladder symptoms and quality of life in Bladder Pain Syndrome /Interstitial Cystitis patients – a pilot, single centre, randomized, double-blind, placebo-controlled trial
To compare efficacy and safety of trigonal injections of onabotulinumtoxinA and saline in Bladder Pain Syndrome/Interstitial Cystitis patients.
Cycling and male sexual and urinary function: results from a large, multinational, cross-sectional study
To explore the relation between cycling and urinary and sexual function in a large, multinational sample of men.
A double-blind, randomized trial on the efficacy and safety of hyperbaric oxygenation therapy in the preservation of erectile function after radical protastectomy
To evaluate the efficacy and safety of hyperbaric oxygenation therapy (HBO2T) in the preservation of erectile function (EF) as part of penile rehabilitation (PR) after robot assisted bilateral nerve sparing radical prostatectomy for prostate cancer.
Topics addressed In this issue of The Journal include the decision making process leading to a Malone antegrade continence enema, the natural history of multicystic dysplastic kidneys (MCDKs), the occurrence of complex reconstruction in patients with spina bifida and the impact of the American Academy of Pediatrics guidelines on the use of voiding cystourethrograms (VCUGs).
A key priority for our profession is to improve shared decision making among men diagnosed with prostate cancer. Especially for men with low risk cancers there is substantial variation in treatment with options that include active surveillance, radiation therapy, radical prostatectomy and now a growing list of ablative therapies.1 Berry et al report that compared to the usual clinical care the web based decision aid P3P significantly reduced decisional conflict in men with localized prostate cancer.
The paradigm of shared decision making is becoming ever more entrenched in the patient-provider dyad for decisions with multiple acceptable alternatives.1 An increasing understanding of the widely variable degree to which patients ascribe value to different aspects of treatments and expected outcomes has contributed to the widespread acceptance of this approach by patients, physicians and policymakers. Despite the acceptance of shared decision making in theory, providers face numerous barriers to executing effective shared decision making in practice.
Urologists have long debated whether lymph node dissection is a staging or therapeutic procedure in patients with high risk RCC. A single randomized 2009 trial, EORTC 30881, was negative but limited by a preponderance of patients at good risk with low stage and grade, and positive nodes in only 4% of patients in the node dissection arm (reference 8 in article).
We agree with the assertion that tests performed in clinical practice should have the potential to influence decision making. With regard to androgen deprivation therapy users who establish an ideal serum testosterone level of less than 20 mg/dl (0.7 nmol/l) it seems that repeat testosterone measurement at each followup visit is unwarranted. Elevated testosterone may develop and appear to have no prognostic significance. This suggests that no immediate change in hormonal regimen is necessary in these patients, especially as in most levels less than 20 mg/dl will be reestablished.
In medicine a test should be performed to influence a decision: no decision, no test. This axiom is accepted in theory and widely ignored in practice. Why? Because we are strongly influenced by the anecdote, a disproportionate recollection of an isolated bad outcome and our compulsive tendencies. Not ordering something is always harder than “just being sure.”
In this novel study the authors used tracking technology to sample prior positive sites at approximately 1-year confirmatory biopsy in 352 men enrolled in an active surveillance program at UCLA. They report upgrading (higher Gleason score at second biopsy) in 26% of men overall. The confirmatory biopsy protocol included a modified repeat systematic biopsy in addition to sampling of all prior positive sites and MRI targets. Only 9% of men underwent repeat MRI prior to confirmatory biopsy.
The optimal strategy for following patients on active surveillance for prostate cancer remains a challenge. In up to 50% of patients on AS no cancer is detected at confirmatory or followup biopsy because there is no guarantee that the cancer site at the initial biopsy session is being sampled.1,2
We appreciate this appraisal and agree that urologists will increasingly be called upon in the care of transgender patients. It is therefore imperative to establish best practice techniques in this advancing field. We concur that future studies investigating patient reported outcomes in gender affirming surgery are paramount. We have previously argued that patient reported outcomes should be the gold standard by which these procedures are judged (reference 26 in article).1 A successful postoperative result has often been judged by a low complication profile.
Ascha et al present a highly informative, retrospective comparison of outcomes of 1-stage phalloplasty by pALT or RFFF in gender confirming neophallus creation. Drawbacks of RFFF include donor site scarring and potential hand/forearm dysfunction. pALT avoids vascular anastomosis and has lower donor site morbidity but carries a risk of higher urethral complications. The authors determine which approach to perform with the patient based on BMI and the desire to avoid donor site morbidity. Future studies should use patient reported outcome measures1 and seek novel ways to improve long-term followup to most accurately estimate procedure complication profiles.
Non-representative biopsy sampling of prostate cancers with a biopsy Gleason score of 8 can adversely influence decisions regarding androgen deprivation among men receiving primary radiation therapy. The frequency of and factors associated with downgrading of Gleason 8 biopsies at prostatectomy are not well known.
Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients
Studies of surgical complications from penile inversion vaginoplasty are limited due to small sample sizes. We describe postoperative complications after penile inversion vaginoplasty and evaluate age, BMI, and years on hormone replacement therapy (HRT) as risk factors for complications.