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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

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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.

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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.

5. Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External Beam Boost for High- and Intermediate-risk Prostate Cancer. Int J Rad Onc Bio Phys 2017; 98: 275-285.

6. Lazarev S, Thompson MR, Stone NN, Stock RG. Low-dose-rate brachytherapy for prostate cancer: outcomes at >10 years of follow-up. BJU Int 2018; 121: 781-790.

7. Langley SEM, Soares R, Uribe J, et al. Long-term oncological outcomes and toxicity in 597 men aged ≤60 years at time of low-dose-rate brachytherapy for localised prostate cancer. BJU Int 2018; 121: 38-45.

Visual abstract: Long-term oncological and functional follow-up in low dose rate brachytherapy for PCa: results from the prospective nation-wide Swiss Registry

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COVID-19 and Prostate Cancer — Challenges and Solutions

The numbers are staggering. As of the date of this brief commentary, the World Health Organization has reported more than 4.6 million cases and upwards of 311,840 deaths worldwide from the COVID-19 pandemic. The virus responsible for the disease known as COVID-19, SARS-CoV-2, is highly infectious and the risks are clearly significant for nearly everyone. Nonetheless, the risk is much higher for some of us than for others. In particular, we have begun to understand the distinct risks faced by men with prostate cancer and the unique intersection of biological, health, and lifestyle factors in COVID-19 and prostate cancer. Although there is a great deal yet to be learned, there are indeed many aspects of the overlap between COVID-19 and prostate cancer that we have already been able to discern and which we have begun to address. Perhaps most striking, older men who are at greatest risk for prostate cancer may also be at greatest risk for COVID-19. 

New York City

Biology Makes a Difference – COVID-19 and prostate cancer share some common biological features. A gene responsible for male traits or characteristics, the androgen receptor, which is dysregulated or impaired in prostate cancer, is also important in COVID-19. Androgens can suppress the body’s immune response to infections and may explain the reason for higher rates of infection in men.  At the same time, a gene known as TMPRSS2 is also highly expressed in both COVID-19 and prostate cancer. In fact, these issues may be related—more androgens could signify greater expression of TMPRSS2 which could create greater susceptibility to the virus. These biological risks are compounded by a number of critical health conditions and lifestyle issues.

Common Risk Factors – Studies from around the world have shown that several chronic health conditions or comorbidities create greater risk for contracting the virus, becoming more severely ill, or dying from COVID-19. It is indeed concerning that many of these are the same risks we see in prostate cancer: hypertension, diabetes, COPD, and obesity. Prostate cancer patients with multiple comorbid conditions may be at even greater risk. Cancer patients in general have weakened immune systems which makes them more vulnerable to infectious disease, further compounding the unique factors affecting men with prostate cancer. Some of the lifestyle factors that may contribute to chronic health conditions also appear to be risk factors for COVID-19 infection, most importantly smoking and high levels of alcohol consumption. We are especially concerned about men who are active smokers, as smoking has been clearly linked to worse outcomes in men who have become ill with COVID-19. We believe that the guidance we generally offer to prostate cancer patients is as, if not more, relevant now in this time of the COVID pandemic—adopt healthy habits, including smoking cessation, a nutritious diet, exercise, and proper management of chronic conditions most notably diabetes.

Looking Ahead – As the pandemic evolves and we look to the future, we are focused on ways to prevent the spread of infection and to create viable treatments for those who become ill. Worldwide, more than nine million men currently face decisions about biopsy, active surveillance, surgery, radiation, hormonal therapy, or chemotherapy related to prostate cancer in the context of COVID-19 and another 3 million more will find themselves facing these decisions by the end of this year. We are working intensely to address their needs. More than 1,460 clinical trials are underway to test therapeutic interventions to treat COVID-19. What we have come to understand about the shared biology between COVID-19 and prostate cancer and common risk factors will be invaluable. We must learn everything we can about the ways in which the virus impacts lung function as it relates to prostate cancer—the respiratory symptoms that result from infection have been especially lethal—and continue to explore the role of androgens in response to new drugs. Many drugs originally intended and approved for other uses are being tested for potential “repurposing” and new drugs and vaccines are under investigation. New clinical guidelines have been established for the treatment of prostate cancer patients at risk of or for those who have contracted the virus, and these guidelines will continue to evolve and be updated.

A Global Perspective – It is critical that we understand the COVID-19 pandemic both on the level of individual experience and global impact. For prostate cancer patients, this means recognizing the way that biology, related chronic health conditions, and lifestyle choices come together to impact the risk of disease, disease severity, and outcomes. Prostate cancer patients and their doctors must come together to find the way forward during this time of unprecedented crisis and opportunities for improving outcomes and quality of life for prostate cancer patients.

Ash Tewari, Zach Dovey and Dimple Chakravarty

Article of the week: Efficacy of vibegron, a novel β3‐adrenoreceptor agonist, on severe UUI related to OAB: post hoc analysis of a randomized, placebo‐controlled, double‐blind, comparative phase 3 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.

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

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

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

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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.

Diary‐dry rate. UUI, urgency urinary incontinence. Data are presented as mean (95% CI). Chi‐squared test, *P < 0.05, **P < 0.001 vs placebo. PBO, placebo group; V 100, vibegron 100 mg group; V 50, vibegron 50 mg group; Wk, week(s).

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.

Article of the week: Prostate cancer in kidney transplant recipients – a nationwide register 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.

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

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

Prostate cancer in kidney transplant recipients – a nationwide register study

Ola Bratt*, Linda Drevin, Karl-Göran Prütz§, Stefan Carlsson, Lars Wennberg** and Pär Stattin††

*Department of Urology, Institute of Clinical Science, Sahlgrenska Academy, Gothenburg University, Department of Urology, Sahlgrenska University Hospital, Gothenburg, Regional Cancer Centre, Uppsala-Orebro, Uppsala, §Swedish Renal Registry, Ryhov Hospital, Jönköping, Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, **Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, and ††Department of Surgical Sciences, Uppsala University, Uppsala, Sweden

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Abstract

Objective

To investigate whether post‐transplantation immunosuppression negatively affects prostate cancer outcomes in male kidney transplant recipients.

Patients and Methods

We used the Swedish Renal Register and the National Prostate Cancer Register to identify all kidney transplantation recipients diagnosed with prostate cancer in Sweden 1998–2016. After linking these registers with Prostate Cancer Database Sweden (PCBaSe), a case‐control study was designed to compare time period and risk category‐specific probabilities of a prostate cancer diagnosis amongst kidney transplantation recipients versus the male general population. The registers did not include information about the specific immunosuppression agent used in all transplantation recipients. Data from PCBaSe were used to compare prostate cancer characteristics at diagnosis and survival for patients with prostate cancer with versus without a kidney transplant. Propensity score matching, Cox regression analysis and Fisher’s exact test were used and 95% confidence intervals (CIs) calculated.

 

Prostate cancer‐specific and overall survival for all 133 Swedish men who were diagnosed with prostate cancer after kidney transplantation between 1998 and 2016, and a control group of 665 men with prostate cancer without a kidney transplant, matched for age, year of prostate cancer diagnosis, educational duration, and county of residence. The curves were constructed with the Kaplan–Meier method. There was no evidence for a difference in cancer‐specific survival (log‐rank test: P = 0.37), but overall survival was shorter (log‐rank test: P = 0.003). KT, kidney transplantation; PC, prostate cancer.

Results

Almost half of the 133 kidney transplantation recipients were transplanted before the mid‐1990s, when PSA testing became common in cancer centers. The transplant recipients were not more likely than age‐matched control men to be diagnosed with any (odds ratio [OR] 0.84, 95% CI 0.70–0.99) or high‐risk or metastatic prostate cancer (OR 0.84, 95% CI 0.62–1.13). None of the ORs for the different categories of prostate cancer increased with time since transplantation. Cancer characteristics at the time of diagnosis and cancer‐specific survival were similar amongst transplant recipients and the control group of 665 men diagnosed with prostate cancer without a kidney transplant.

Conclusions

This Swedish nationwide, register‐based study gave no indication that immunosuppression after kidney transplantation increases the risk of prostate cancer or adversely affects prostate cancer outcomes. The study suggests that men with untreated low‐grade prostate cancer can be accepted for transplantation.

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Editorial: Prostate cancer and kidney transplantation – exclusion or co‐existence?

Untreated prostate cancer is generally a contraindication to kidney transplantation. At our institution in Boston, we are often referred individuals with low‐volume low‐risk prostate cancer for treatment. For a cancer that would otherwise be managed with active surveillance, these kidney transplantation candidates will often be forced into some form of definitive therapy, generally radical prostatectomy, a procedure with a well‐known long‐term side‐effect profile, and then have to wait for a period of time, generally 2 years, before being considered for transplantation. The basis for this approach stems from the theoretical higher risk of disease progression and ultimately mortality on immunosuppression. In this issue of the BJU International, Bratt et al. [1] challenge these assumptions and report on the outcomes of kidney transplant recipients diagnosed with prostate cancer. First, they found no difference in prostate cancer incidence, suggesting that transplant recipients, despite being immunosuppressed, are not at higher risk of prostate cancer. Second, they found that the prostate cancer characteristics at diagnosis, overall and prostate cancer‐specific survival of kidney transplant recipients do not differ significantly from non‐transplant patients. Furthermore, the probability of developing advanced prostate cancer over time was not higher among transplant recipients on immunosuppression. Taken together, these findings show that transplant patients are not at a higher risk of poor prostate cancer outcomes.

Hypothesising that many of the transplant recipients in this study already had prostate cancer when they underwent transplantation (based on assumptions about cancer screening practices in Sweden and the time periods included), the authors aim to refute current transplantation guidelines contraindicating solid organ transplantation in those with a history of prostate cancer and requiring a minimum recurrence‐free period before placing these patients on the organ waiting list [23]. The findings of Bratt et al. [1] corroborate previous case series including the largest study of cancer incidence among transplant recipients and a meta‐analysis of six studies. Given the available data, is it still justifiable to deny patients with low‐risk prostate cancer life‐saving kidney transplantation? If the answer is ‘no’, what would be fair cutoffs in Gleason score, number of positive biopsy cores, PSA level, time from diagnosis, etc.? While this study does not definitely answer the question, it would seem reasonable that candidates for active surveillance, especially those with very low‐risk prostate cancer, should be eligible for kidney transplantation without prior definitive therapy. Denying immediate placement on the waiting list represents not only a significant reduction of quality of life, but also leads to reduced survival due to longer dialysis time.

Another concern often heard from those in favour of definitive therapy before transplantation is the added risks of prostatectomy in immunosuppressed individuals; this is understandable given that the incidence of definitive therapy on active surveillance is ~50% at 10 years after diagnosis [4]. However, the available data suggest that prostatectomy after transplantation is safe. For example, in a recent systematic review, only one of 35 patients had a Clavien ≥ 3 complication and graft function was maintained in all patients [5]

To summarise, this study [1], and others before that, suggests that immunosuppression after kidney transplantation is unlikely to adversely affect prostate cancer initiation or progression. Men with low‐risk prostate cancer should be considered for transplantation without first undergoing definitive therapy. There is evidence around the world, and at our institution, that transplant specialists are finally starting to accept this pathway. This study will further reinforce this concept.

by Lorine Haeuser, David‐Dan Nguyen Quoc‐Dien Trinh

References

  1. Bratt O, Drevin L, Prütz K‐G, Carlsson S, Wennberg L, Stattin P. Prostate cancer in kidney transplant recipients – a nationwide register study. BJU Int 2020; 125: 679– 85
  2. Murray KF, Carithers RL. AASLD practice guidelines: evaluation of the patient for liver transplantation. Hepatology 2005; 41: 1407– 32
  3. Oechslin E, Kiowski W, Schneider J, Follath F, Turina M, Gallino A. Pretransplant malignancy in candidates and posttransplant malignancy in recipients of cardiac transplantation. Ann Oncol 1996; 7: 1059– 63
  4. Tosoian JJ, Mamawala M, Epstein JI et al. Intermediate and longer‐term outcomes from a prospective active‐surveillance program for favorable‐risk prostate cancer. J Clin Oncol 2015; 33: 3379– 85
  5. Zeng J, Christiansen A, Pooli A, Qiu F, LaGrange CA. Safety and clinical outcomes of robot‐assisted radical prostatectomy in kidney transplant patients: a systematic review. J Endourol 2018; 32: 935– 43
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