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Article of the week: Single-port robot assisted radical prostatectomy (SP-RARP): a systematic review and pooled analysis of the preliminary experiences

This is the final Article of the Week selected by the outgoing Editor-in-Chief from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, we recommend this one. 

Single‐port robot‐assisted radical prostatectomy: a systematic review and pooled analysis of the preliminary experiences

Enrico Checcucci*, Sabrina De Cillis*, Angela Pecoraro*, Dario Peretti*, Gabriele Volpi*, Daniele Amparore*, Federico Piramide*, Alberto Piana*, Matteo Manfredi*, Cristian Fiori*, Riccardo Autorino, Prokar Dasgupta, Francesco Porpiglia* and on behalf of the Uro-technology and SoMe Working Group of the Young Academic Urologists Working Party of the European Association of Urology

*Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy, Division of Urology, VCU Health, Richmond, VA, USA, and King’s College London, Guy’s Hospital, London, UK

Abstract

Objective

To summarize the clinical experiences with single‐port (SP) robot‐assisted radical prostatectomy (RARP) reported in the literature and to describe the peri‐operative and short‐term outcomes of this procedure.

Material and Methods

A systematic review of the literature was performed in December 2019 using Medline (via PubMed), Embase (via Ovid), Cochrane databases, Scopus and Web of Science (PROSPERO registry number 164129). All studies that reported intra‐ and peri‐operative data on SP‐RARP were included. Cadaveric series and perineal or partial prostatectomy series were excluded.

The da Vinci SP robotic platform

Results

The pooled mean operating time, estimated blood loss, length of hospital stay and catheterization time were 190.55 min, 198.4 mL, 1.86 days and 8.21 days, respectively. The pooled mean number of lymph nodes removed was 8.33, and the pooled rate of positive surgical margins was 33%. The pooled minor complication rate was 15%. Only one urinary leakage and one major complication (transient ischaemic attack) were recorded. Regarding functional outcomes, pooled continence and potency rates at 12 weeks were 55% and 42%, respectively.

Conclusions

The present analysis confirms that SP‐RARP is safe and feasible. This novel robotic platform resulted in similar intra‐operative and peri‐operative outcomes to those obtained with the standard multiport da Vinci system. The advantages of single incision can be translated into a preservation of the patient’s body image and self‐esteem and cosmesis, which have a great impact on a patient’s quality of life.

Article of the week: Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for BPH

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

There is also an editorial written by a prominent member of the urological community. Please use the comment buttons if you would like to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Critical analysis of a multicentric experience with holmium laser enucleation of the prostate for benign prostatic hyperplasia: outcomes and complications of 10 years of routine clinical practice

Javier Romero-Otero*†‡, Borja García-Gómez*, Lucía García-González*, Esther García-Rojo*, Pablo Abad-López*, Juan Justo-Quintas, José Duarte-Ojeda* and Alfredo Rodríguez-Antolín*

*Urology Department, Grupo de Investigación Salud Integral del Varón imas12, Hospital Universitario 12 Octubre, Hospital Universitario HM Montepríncipe, and Hospital Universitario La Luz, Madrid, Spain

Abstract

Objective

To assess the perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in real‐life practice and investigate the factors influencing the safety and effectiveness of the technique.

Patients and Methods

Critical analysis of patients with benign prostate hyperplasia (BPH) treated with HoLEP over 10 years of routine practice in three hospitals. Analysed variables included: preoperative characteristics (prostate size, active antiplatelet/anticoagulant therapy, blood parameters. prostate‐specific antigen (PSA) level, maximum urinary flow rate [Qmax], and International Prostate Symptom Score [IPSS]), intraoperative variables (operation time, concomitant removal of bladder calculi, and complications), early postoperative outcomes (change in blood parameters, catheterisation time, and hospital stay), and 12‐month follow‐up outcomes (change in IPSS, PSA level, and Qmax).

Results

The analysis included 963 patients, aged 48–91 years, with a mean (range) prostate size of 91 (35–247) mL. The mean (sd ) operation time was 77 (29) min, and the hospital stay and catheterisation time were 4 (2) and 1.3 (2) days, respectively. In all, 56 patients (5.6%) required concomitant removal of bladder calculi and 36 (3.7%) were converted to open prostatectomy or transurethral resection of the prostate due to intraoperative complications. Patients had a significant decrease in haemoglobin and haematocrit, but no differences were seen between patients with and without anticoagulant/antiplatelet therapy and those with prostates ≥ and <100 mL. The concomitant removal of bladder calculi and having a prostate ≥100 mL resulted in a longer operation time, but did not influence the safety and effectiveness outcomes.

Conclusions

HoLEP is suitable for real‐life patients with BPH, irrespective of the presence of active treatment with anticoagulant/antiplatelet, bladder lithiasis or a prostate ≥100 mL.

Article of the week: Management of large renal stones with super‐mini percutaneous nephrolithotomy: an international multicentre comparative study

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

There is also a visual abstract created by Cora Griffin from King’s College London.

If you only have time to read one article this week, we recommend this one. 

Management of large renal stones with super-mini percutaneous nephrolithotomy: an international multicentre comparative study

Yang Liu*, Chao Cai*, Albert Aquino, Shabir Al-Mousawi, Xuepei Zhang§, Simon K.S. Choong, Xiang He**, Xianming Fan††, Bin Chen‡‡, Jianhua Feng§§, Xuhui Zhu¶¶, Abdulla Al-Naimi***, Houping Mao†††, Huilong Tang‡‡‡, Dayong Jin§§§, Xiancheng Li¶¶¶, Fenghong Cao****, Hua Jiang††††, Yongfu Long‡‡‡‡, Wei Zhang§§§§, Gang Wang¶¶¶¶, Zihao Xu*, Xin Zhang*, Shanfeng Yin* and Guohua Zeng*

*Department of Urology, Guangdong Key Laboratory of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China, Department of Urology, Jose R. Reyes Memorial Medical Center, Manila, Philippines, Division of Urology, SABAH ALAHMAD Urology Center, Ministry of Health, Al-Amiri Hospital, Kuwait City, Kuwait, §Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China, Institute of Urology, University College London Hospitals, London, UK, **Department of Urology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, ††Department of Urology, The Third Affiliated Hospital of Xiamen, The Third Affiliated Hospital of Fujian University of Traditional Chinese Medicine, ‡‡Department of Urology, The Affiliated Hospital of Xiamen University, Xiamen, §§Department of Urology, Longgang District Central Hospital, Shenzhen, ¶¶Department of Urology, Beijing Chaoyang Hospital, Affiliated to Capital Medical University, Beijing, China, ***Department of Urology, Hamad Medical Corporation, Doha, Qatar, †††Department of Urology, First Affiliated Hospital of Fujian Medical University, Fuzhou, ‡‡‡Department of Urology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha, §§§Department of Urology, Liaoyuan City Central Hospital, Liaoyuan, ¶¶¶Department of Urology, Second Affiliated Hospital of Dalian Medical University, Dalian, ****Department of Urology, North China University of Science and Technology Affiliated Hospital, Tangshan, ††††Department of Urology, Zhongda Hospital Southeast Hospital, Nanjing, ‡‡‡‡Department of Urology, Central Hospital of Shaoyang, Shaoyang, §§§§Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, and ¶¶¶¶Department of Urology, National Urological Cancer Center, Institute of Urology, Peking University First Hospital, Peking University, Beijing, China

Abstract

Objectives

To comparatively evaluate the clinical outcomes of super‐mini percutaneous nephrolithotomy (SMP) and mini‐percutaneous nephrolithotomy (Miniperc) for treating urinary tract calculi of >2 cm.

Patients and Methods

An international multicentre, retrospective cohort study was conducted at 20 tertiary care hospitals across five countries (China, the Philippines, Qatar, UK, and Kuwait) between April 2016 and May 2019. SMP and Miniperc were performed in 3525 patients with renal calculi with diameters of >2 cm. The primary endpoint was the stone‐free rate (SFR). The secondary outcomes included: blood loss, operating time, postoperative pain scores, auxiliary procedures, complications, tubeless rate, and hospital stay. Propensity score matching analysis was used to balance the selection bias between the two groups.

Results

In all, 2012 and 1513 patients underwent SMP and Miniperc, respectively. After matching, 1380 patients from each group were included for further analysis. Overall, there was no significant difference in the mean operating time or SFR between the two groups. However, the hospital stay and postoperative pain score were significantly in favour of SMP (both  < 0.001). The tubeless rate was significantly higher in the SMP group (72.6% vs 57.8%,  < 0.001). Postoperative fever was much more common in the Miniperc group (12.0% vs 8.4%,  = 0.002). When the patients were further classified into three subgroups based on stones diameters (2–3, 3–4, and >4 cm). The advantages of SMP were most obvious in the 2–3 cm stone group and diminished as the size of the stone increased, with longer operating time in the latter two subgroups. Compared with Miniperc, the SFR of SMP was comparable for 3–4 cm stones, but lower for >4 cm stones. There was no statistical difference in blood transfusions and renal embolisations between the two groups.

Conclusions

Our data showed that SMP is an ideal treatment option for stones of <4 cm and is more efficacious for stones of 2–3 cm, with lesser postoperative fever, blood loss, and pain compared to Miniperc. SMP was less effective for stones of >4 cm, with a prolonged operating time.

Article of the week: Deep learning computer vision algorithm for detecting kidney stone composition

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, we recommend this one. 

Deep learning computer vision algorithm for detecting kidney stone composition

Kristian M. Black*, Hei Law, Ali Aldoukhi*, Jia Deng and Khurshid R. Ghani*

*Department of Urology, University of Michigan, Ann Arbor, MI, and Department of Computer Science, Princeton University, Princeton, NJ, USA

Abstract

Objectives

To assess the recall of a deep learning (DL) method to automatically detect kidney stones composition from digital photographs of stones.

Materials and Methods

A total of 63 human kidney stones of varied compositions were obtained from a stone laboratory including calcium oxalate monohydrate (COM), uric acid (UA), magnesium ammonium phosphate hexahydrate (MAPH/struvite), calcium hydrogen phosphate dihydrate (CHPD/brushite), and cystine stones. At least two images of the stones, both surface and inner core, were captured on a digital camera for all stones. A deep convolutional neural network (CNN), ResNet‐101 (ResNet, Microsoft), was applied as a multi‐class classification model, to each image. This model was assessed using leave‐one‐out cross‐validation with the primary outcome being network prediction recall.

Fig.2. Representative samples for each stone composition prior to cropping. A total of 63 stones were used in this study including: 17 UA, 21 COM, seven struvite, four cystine, and 14 brushite stones consisting of a total of 127 images. Automatic stone composition recall was highest for UA stones at 94%.

Results

The composition prediction recall for each composition was as follows: UA 94% ( = 17), COM 90% ( = 21), MAPH/struvite 86% ( = 7), cystine 75% ( = 4), CHPD/brushite 71% ( = 14). The overall weighted recall of the CNNs composition analysis was 85% for the entire cohort. Specificity and precision for each stone type were as follows: UA (97.83%, 94.12%), COM (97.62%, 95%), struvite (91.84%, 71.43%), cystine (98.31%, 75%), and brushite (96.43%, 75%).

Conclusion

Deep CNNs can be used to identify kidney stone composition from digital photographs with good recall. Future work is needed to see if DL can be used for detecting stone composition during digital endoscopy. This technology may enable integrated endoscopic and laser systems that automatically provide laser settings based on stone composition recognition with the goal to improve surgical efficiency.

Article of the week: Modifiable lifestyle behaviours impact the health‐related quality of life of bladder cancer survivors

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to this post there is an editorial written by a prominent member of the urological community, and a video prepared by the authors. Please use the comment buttons below if you would like to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Modifiable lifestyle behaviours impact the health‐related quality of life of bladder cancer survivors

Jiil Chung*, Girish S. Kulkarni, Jackie Bender*, Rodney H. Breau, David Guttman§, Manjula Maganti*, Andrew Matthew, Robin Morash**, Janet Papadakos†† and Jennifer M. Jones*

*Cancer Rehabilitation and Survivorship Program, Princess Margaret Cancer Centre, Division of Urology, Departments of Surgery and Surgical Oncology, University Health Network and University of Toronto, Toronto, ON, Division of Urology, The Ottawa Hospital and University of Ottawa, Ottawa, §Bladder Cancer Canada, Toronto, ON, Psychosocial Oncology Program, Princess Margaret Cancer Centre, **Wellness Beyond Cancer Program, The Ottawa Hospital, Ottawa, and ††Oncology Education Program, Princess Margaret Cancer Centre, Toronto, ON, Canada

Abstract

Objective

To examine health behaviours in bladder cancer survivors including physical activity (PA), body mass index, diet quality, smoking and alcohol consumption, and to explore their relationship with health‐related quality of life (HRQoL).

Subjects/Patients and Methods

Cross‐sectional questionnaire packages were distributed to bladder cancer survivors (muscle‐invasive bladder cancer [MIBC] and non‐muscle‐invasive bladder cancer [NMIBC]) aged >18 years, and proficient in English. Lifestyle behaviours were measured using established measures/questions, and reported using descriptive statistics. HRQoL was assessed using the validated Bladder Utility Symptom Scale, and its association with lifestyle behaviours was evaluated using analysis of covariance (ancova) and multivariate regression analyses. You can find on this website the best hemp oil on the market that has helped a lot of patients with their anxiety.

Fig.1. *HRQoL (mean ± se ) for total health behaviour. *Mean adjusted for education status, MIBC or NMIBC diagnosis, and time since diagnosis.

Results

A total of 586 participants completed the questionnaire (52% response rate). The mean (SD) age was 67.3 (10.2) years, and 68% were male. PA guidelines were met by 20% ( = 117) and 22.7% ( = 133) met dietary guidelines. In all, 60.9% ( = 357) were overweight/obese, and the vast majority met alcohol recommendations ( = 521, 92.5%) and were current non‐smokers ( = 535, 91.0%). Health behaviours did not differ between MIBC and NMIBC, and cancer treatment stages. Sufficient PA, healthy diet, and non‐smoking were significantly associated with HRQoL, and the number of health behaviours participants engaged in was positively associated with HRQoL ( < 0.001).

Conclusion

Bladder cancer survivors are not meeting guidelines for important lifestyle behaviours that may improve their overall HRQoL. Future research should investigate the impact of behavioural and educational interventions for health behaviours on HRQoL in this population.

Editorial: How can we motivate patients with bladder cancer to help themselves?

Wash your hands. Cover your mouth when you cough. Do not spread germs. We have all heard these hygiene mantras growing up, but we must admit that compliance has not always been perfect. With the coronavirus disease 2019 (COVID‐19) pandemic raising mounting alarm, fear has persuaded unprecedented adherence to hygiene principles globally, as we try to stop the spread of this novel virus.

What motivates a change in behaviour? What motivates someone to stop a bad habit and adopt a good one? Can clinicians aid in this motivation?

Chung et al. [1] performed a cross‐sectional study evaluating health behaviours including physical activity, diet, body mass index, alcohol consumption, and smoking status, as well as health‐related quality of life (HRQoL) in patients with bladder cancer at different treatment stages. In their study sample, most of the patients with bladder cancer were overweight or obese, did not adhere to healthy diet recommendations, were unwilling to change their eating habits, and did not meet guidelines for weekly physical activity. However, patients who had adopted healthy behaviours reported a better HRQoL and more healthy behaviours correlated with a better HRQoL. No difference was found when comparing the health behaviours of patients with non‐muscle vs muscle‐invasive bladder cancer (MIBC) or comparing patients at different stages of treatment. This implies that patients’ health behaviour does not change despite bladder cancer diagnosis and treatment; however, pre‐diagnosis data were unavailable for comparison. Interestingly, the large majority of the patients with bladder cancer were non‐smokers (81%), despite most (71%) reporting a prior history of smoking. What led to a change in smoking status when it appears that no other health behaviour changed with diagnosis and treatment of bladder cancer?

Gallus et al. [2] surveyed 3075 ex‐smokers in Italy to answer the question: why do smokers quit? The most frequently reported reason for smoking cessation (43.2%) was a current health problem. Smoking has been linked to the development of numerous medical conditions and is a well‐established risk factor for bladder cancer. Thus, a new diagnosis of bladder cancer undoubtedly serves as a strong motivator for smoking cessation. The benefits of a healthy diet and regular physical activity on one’s health are less defined. Furthermore, the definitions of a ‘healthy’ diet and ‘regular’ physical activity are variable, making counselling about these behaviours confusing and difficult. Dolor et al. [3] found that physicians feel inadequately trained to provide diet counselling to patients as compared to smoking cessation counselling. Additionally, physicians agreed that counselling regarding weight loss, diet, and physical activity requires too much time compared to smoking cessation counselling. These discrepancies may help explain why physicians were more likely to discuss smoking cessation with patients compared to weight loss, diet, and physical activity in a study by Nawaz et al. [4].

At our own institution, we have found that HRQoL significantly declines in patients with bladder cancer after diagnosis relative to controls, with more pronounced decreases seen in patients with MIBC [5]. Patients with bladder cancer are a vulnerable population who face many medical and personal challenges. As clinicians, we should equip these patients with the proper tools to succeed during bladder cancer treatment, including counselling regarding healthy behaviours. Inviting the help of specialists, such as nutritionists and physical therapists, to discuss the importance of diet and exercise early during treatment may be advantageous for patients and more likely to motivate patients to adopt these healthy behaviours. Furthermore, given the paucity of data linking the health behaviours of patients with bladder cancer to HRQoL, studies such as this one [1] could provide much‐needed evidence to persuade patients regarding the positive impact that healthy behaviour can have on their HRQoL. If we can successfully motivate patients with bladder cancer to adopt healthy behaviours, then their HRQoL will likely improve.

by Hannah McCloskey, Judy Hamad, Angela B. Smith

References

  1. Chung J, Kulkarni GS, Bender J et al. Modifiable lifestyle behaviours impact the health‐related quality of life of bladder cancer survivors. BJU Int 2020; 125: 836– 42
  2. Gallus S, Muttarak R, Franchi M et al. Why do smokers quit? Eur J Cancer Prev 2013; 22: 96– 101
  3. Dolor RJ, Østbye T, Lyna P et al. What are physicians’ and patients’ beliefs about diet, weight, exercise, and smoking cessation counseling? Prev Med 2010; 51: 440– 2
  4. Nawaz H, Adams ML, Katz DL. Physician–patient interactions regarding diet, exercise, and smoking. Prev Med 2000; 31: 652– 7
  5. Smith AB, Jaeger B, Pinheiro LC et al. Impact of bladder cancer on health‐related quality of life. BJU Int 2018; 121: 549– 57

Article of the week: The effect of the urinary and faecal microbiota on lower urinary tract symptoms measured by the International Prostate Symptom Score: analysis utilising next‐generation sequencing

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

Please use the comment buttons below if you would like to join the conversation.

If you only have time to read one article this week, we recommend this one. 

The effect of the urinary and faecal microbiota on lower urinary tract symptoms measured by the International Prostate Symptom Score: analysis utilising next‐generation sequencing

Bradley Holland*, Mallory Karr*, Kristin Delfino*, Danuta Dynda, Ahmed El-Zawahry, Andrea Braundmeier-Fleming*, Kevin McVary§ and Shaheen Alanee

*Southern Illinois University School of Medicine, Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA, Urology, University of Toledo, Toledo, OH, §Loyola University Chicago, Chicago, IL, and Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA

Abstract

Objective

To examine the correlation between urinary and faecal microbial profiles and the different aspects of lower urinary tract symptoms (LUTS) in men, as there is accumulating evidence that variations in the human microbiota may promote different benign disease conditions.

Patients and Methods

We extracted total DNA from urine and faecal samples of a group of men, under an Institutional Review Board‐approved protocol. At the same time, International Prostate Symptom Score (IPSS) data were collected. We then amplified the extracted DNA and sequenced it using bacterial 16S ribosomal RNA gene high‐throughput next‐generation sequencing platform, and analysed the microbial profiles for taxonomy to examine the correlation between the different operational taxonomy units (OTUs) and LUTS represented by the total IPSS, the different symptom levels of the IPSS (mild, moderate, and severe) and its subcomponents of storage, nocturia, voiding, and bother.

Results

We included 30 patients (60 samples; one urine and one faecal per patient). In all, 48 faecal OTUs showed a significant correlation with one or more of the IPSS components; 27 with nocturia, 19 with bother, 16 with storage symptoms, and nine with voiding symptoms. The most substantial negative (protective) correlation was between Lachnospiraceae Blautia , a bacteria that increases the availability of gut anxiolytic and antidepressant short‐chain fatty acids, and bother (correlation coefficient 0.702; P  = 0.001). The abundance of L. Blautia continued to have a protective correlation against LUTS when looking at the different levels of IPSS severity (moderate and severe vs mild, correlation coefficient 0.6132; P =  0.002). Ten unique urinary OTUs showed significant correlation with LUTS; eight with nocturia, one with bother, three with storage, and one with voiding, but no faecal OUT had more than a low correlation with the outcomes of interest in this study.

Conclusions

Our prospective work finds a plausible correlation between L. Blautia and LUTS. Additional studies are needed to determine if the correlations found in the present research are applicable to the general population of patients affected by LUTS.

Article of the month: Long‐term oncological and functional follow‐up in low‐dose‐rate brachytherapy for PCa: results from the prospective nationwide Swiss registry

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to this post there is also an Editorial written by a prominent member of the urological community and a visual abstract created by Cora Griffin at King’s College London. We invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, we recommend this one. 

Long‐term oncological and functional follow‐up in low‐dose‐rate brachytherapy for prostate cancer: results from the prospective nationwide Swiss registry

Pascal Viktorin-Baier*, Paul M. Putora‡§, Hans-Peter Schmid*, Ludwig Plasswilm‡§, Christoph Schwab*, Armin Thoeni, Werner Hochreiter**, Ladislav Prikler††, Stefan Suter‡‡, Patrick Stucki, Michael Müntener§§, Nadja Blick§§, Hans Schiefer, Sabine Güsewell¶¶, Karin Zürn* and Daniel Engeler*

*Department of Urology, St. Gallen Cantonal Hospital, St. Gallen, Urology Clinic, Cantonal Hospital Lucerne, Lucerne, Department of Radiation Oncology, St. Gallen Cantonal Hospital, St. Gallen, §Department of Radiation Oncology, University of Berne, Clinic for Radiation-Oncology, Lindenhof Hospital Berne, Berne, **Urology Clinic, Hirslanden Clinic Aarau, Aarau, ††Urology Clinic, Uroviva Clinic Buelach, Buelach, ‡‡Urology Clinic Zug, Zug, §§Urology Clinic, Triemli Hospital, Zurich, and ¶¶Clinical Trial Unit, St. Gallen Cantonal Hospital, St. Gallen, Switzerland

Abstract

Objective

To evaluate the long‐term oncological, functional and toxicity outcomes of low‐dose‐rate brachytherapy (LDR‐BT) in relation to risk factors and radiation dose in a prospective multicentre cohort.

Patients and Methods

Data of patients from 12 Swiss centres undergoing LDR‐BT from September 2004 to March 2018 were prospectively collected. Patients with a follow‐up of ≥3 months were analysed. Functional and oncological outcomes were assessed at ~6 weeks, 6 and 12 months after implantation and annually thereafter. LDR‐BT was performed with 125I seeds. Dosimetry was done 6 weeks after implantation based on the European Society for Radiotherapy and Oncology recommendations. The Kaplan–Meier method was used for biochemical recurrence‐free survival (BRFS). A prostate‐specific antigen (PSA) rise above the PSA nadir + 2 was defined as biochemical failure. Functional outcomes were assessed by urodynamic measurement parameters and questionnaires.

Results

Of 1580 patients in the database, 1291 (81.7%) were evaluable for therapy outcome. The median (range) follow‐up was 37.1 (3.0–141.6) months. Better BRFS was found for Gleason score ≤3+4 ( = 0.03, log‐rank test) and initial PSA level of <10 ng/mL ( < 0.001). D’Amico Risk groups were significantly associated with BRFS ( < 0.001), with a hazard ratio of 2.38 for intermediate‐ and high‐risk patients vs low‐risk patients. The radiation dose covering 90% of the prostate volume (D90) after 6 weeks was significantly lower in patients with recurrence. Functional outcomes returned close to baseline levels after 2–3 years. A major limitation of these findings is a substantial loss to follow‐up.

Conclusion

Our results are in line with other studies showing that LDR‐BT is associated with good oncological outcomes together with good functional results.

Editorial: Low-dose-rate brachytherapy for prostate cancer stands the test of time – the Swiss experience

The clinical results from 12 Swiss centres reaffirm the benefits of Low Dose Rate Brachytherapy (LDR-BT) for the treatment of localised prostate cancer [1]. The authors are to be commended for collating and analysing prospective, countrywide, long-term data. This is an excellent example of Good Clinical Practice for the urology community, patients, commissioning groups and for governance purposes. Prostate brachytherapy offers suitable men with prostate cancer a high chance of long-term cure but with a low risk of urinary incontinence and most retaining erectile dysfunction [2].

Two thirds of the patients reported in the Swiss series had low-risk cancer who would now more commonly be offered active surveillance as an initial treatment option. However our own and other large mature series have shown similar treatment efficacy of LDR-BT, either as monotherapy as in the Swiss study, or as a boost to external-beam radiotherapy, for the treatment of patients with intermediate and high risk of disease relapse [3, 4]. Indeed the ASCENDE-RT trial recently showed that men with unfavourable intermediate or high-risk prostate cancer randomised to an LDR-BT boost arm, relative to a dose-escalated external-beam radiotherapy boost, were twice as likely to be free of biochemical failure at a median follow-up of 6.5 years. A slight increase in urinary toxicity was observed which may have been an issue related to implant technique [5].

The authors show LDR-BT affords excellent disease control that associates with post-implant dosimetry in keeping with current treatment guidelines. They also report an association between biochemical control and seed loss. It therefore becomes unclear the extent to which implant quality or implant technique, i.e. the use of loose or stranded seeds, influenced the oncological outcome, as it would appear that more than one brachytherapy technique has been used.

In this series no prostate cancer-related deaths were reported. However the median follow-up length of 37 months is relatively short. Examples from more mature series show longer follow-up is needed to begin to document the low rates of prostate cancer-related deaths following LDR-BT. Lazarev et al [6] in a similar risk group distribution to the Swiss population, reported 97% prostate cancer-specific survival at 17-years with all deaths occurring more than 10 years after treatment. Morris et al [4] reported 99.1% cause-specific survival at 10 years with death events 9 years after treatment in low and intermediate-risk disease. Our own series showed 98% prostate-cancer-specific survival at 7 and 9 years post-implantation in high-risk (as defined by NICE) patients treated with monotherapy [3].

Treatment-related toxicity assessments in the Swiss series showed that baseline values are crucial to understand the impact of treatment on patient-reported outcomes. Higher post-implant scores were consistently observed in those patients with higher baseline scores. The patient-reported outcomes were similar to those from our series where sexual potency was preserved in 70-80% of men who were ≤60 years old at time of implant [7].

Salvage therapies are seldom given after LDR-BT as the local failure rate is low and the surgery complex. It was undertaken in only two patients in the Swiss series. In the era of mp-MRI and PSMA PET/CT scans and targeted biopsies, tumour recurrence can be better assessed.  Salvage surgery has been offered to approximately 0.5% (27/4200) of our patients, by either robotic-assisted radical prostatectomy or seminal vesiculectomy if the recurrence is localised to the seminal vesicle alone.

This nation-wide report from the 12 Swiss centres is a welcome addition to the extensive body of evidence that attests to the excellent results and generalisability of prostate LDR-BT. The treatment is efficacious and convenient for patients with a low toxicity profile. It is a cost effective option that should be offered to all suitable patients with localised prostate cancer.

by Stephen Langley

References

1. Viktorin-Baier P, Putora PM, Schmid HP, et al. Long-term oncological and functional follow-up in low-dose-rate brachytherapy for prostate cancer: results from the prospective nationwide Swiss registry. BJU Int 2020: 125(6).

2. Punnen S, Cowan JE, Chan JM, Carroll PR, Cooperberg MR. Long-term health-related quality of life after primary treatment for localized prostate cancer: results from the CaPSURE registry. European urology 2015; 68: 600-608.

3. Laing R, Uribe J, Uribe-Lewis S, et al. Low-dose-rate brachytherapy for the treatment of localised prostate cancer in men with a high risk of disease relapse. BJU Int 2018; 122: 610-617.

4. Morris WJ, Keyes M, Spadinger I, et al. Population-based 10-year oncologic outcomes after low-dose-rate brachytherapy for low-risk and intermediate-risk prostate cancer. Cancer 2013; 119: 1537-1546.

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Residents’ Podcast: Efficacy of vibegron, a novel β3‐adrenoreceptor agonist, on severe UUI related to OAB

Part of the BURST/BJUI Podcast Series

Nikita Bhatt is a Specialist Trainee in Urology in the East of England Deanery and a BURST Committee member @BURSTUrology

Efficacy of vibegron, a novel β3‐adrenoreceptor agonist, on severe urgency urinary incontinence related to overactive bladder: post hoc analysis of a randomized, placebo‐controlled, double‐blind, comparative phase 3 study

Masaki Yoshida*, Masayuki Takeda, Momokazu Gotoh, Osamu Yokoyama§, Hidehiro Kakizaki, Satoru Takahashi**, Naoya Masumori††, Shinji Nagai‡‡ and Kazuyoshi Minemura‡‡

*Department of Urology, National Centre for Geriatrics and Gerontology, Obu, Department of Urology, University of Yamanashi, Graduate School of Medical Sciences, Kofu, Japan, Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, §Department of Urology, Faculty of Medical Science, University of Fukui, Fukui, Department of Renal and Urological Surgery, Asahikawa Medical University, Asahikawa, Japan, **Department of Urology, Nihon University School of Medicine, Tokyo, ††Department of Urology, Sapporo Medical University School of Medicine, Sapporo, and ‡‡Kyorin Pharmaceutical Co., Ltd., Tokyo, Japan

Abstract

Objective

To evaluate the efficacy of a novel and selective β3‐adrenoreceptor agonist vibegron on urgency urinary incontinence (UUI) in patients with overactive bladder (OAB).

Patients and Methods

post hoc analysis was performed in patients with UUI (>0 episodes/day) who were assigned to receive vibegron or placebo in a vibegron phase 3 study. Patients were subclassified into mild/moderate (>0 to <3 UUI episodes/day) or severe UUI (≥3 UUI episodes/day) subgroup. Changes from baseline in number of UUI episodes/day, in number of urgency episodes/day, and in voided volume/micturition were compared between the groups. The percentage of patients who became UUI‐free (‘diary‐dry’ rate) and the response rate (percentage of patients with scores 1 [feeling much better] or 2 [feeling better] assessed by the Patient Global Impression scale [PGI]) were evaluated.

Results

Changes in numbers of UUI episodes at week 12 in the vibegron 50 mg, vibegron 100 mg and placebo groups, respectively, were −1.35, −1.47 and −1.08 in all patients, −1.04, −1.13 and −0.89 in the mild/moderate UUI subgroup, and −2.95, −3.28 and −2.10 in the severe UUI subgroup. The changes were significant in the vibegron 50 and 100 mg groups vs placebo regardless of symptom severity. Change in number of urgency episodes/day was significant in the vibegron 100 mg group vs placebo in all patients and in both severity subgroups. In the vibegron 50 mg group, a significant change vs placebo was observed in all patients and in the mild/moderate UUI subgroup. Change in voided volume/micturition was significantly greater in the vibegron 50 and 100 mg groups vs placebo in all patients, as well as in the both severity subgroups. Diary‐dry rates in the vibegron 50 and 100 mg groups were significantly greater vs placebo in all patients and in the mild/moderate UUI subgroup. In the severe UUI subgroup, however, a significant difference was observed only in the vibegron 50 mg group. Response rates assessed by the PGI were significantly higher in the vibegron groups vs placebo in all patients and in the both severity subgroups. Vibegron administration, OAB duration ≤37 months, mean number of micturitions/day at baseline <12.0 and mean number of UUI episodes/day at baseline <3.0 were identified as factors significantly associated with normalization of UUI.

Conclusions

Vibegron, a novel β3‐adrenoreceptor agonist, significantly reduced the number of UUI episodes/day and significantly increased the voided volume/micturition in patients with OAB including those with severe UUI, with the response rate exceeding 50%. These results suggest that vibegron can be an effective therapeutic option for OAB patients with UUI.

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