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Editorial: The BAUS consensus documents on andrology

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In 2018, the BAUS returns to Liverpool and we have taken this opportunity to renew the lasting friendship between the BAUS and the BJUI. We also celebrate a monumental achievement for the city of Liverpool itself – the Knighthood of Sir Ringo Starr. This has finally happened, 50 years after his MBE and is richly deserved. We therefore decided to feature Liverpool and The Beatles on the front cover of your journal.

This year, Duncan Summerton, a well‐respected Urologist and Andrologist, starts his 2‐year term as the President of the BAUS. In our ‘Guidelines’ section, we have featured two BAUS consensus documents from the Andrology Section on priapism [1] and testicular trauma [2]. The former has an excellent flow chart on management of priapism with timelines of presentation, which every urologist will find clinically useful.

We have also included two excellent UK articles on renal trauma [3, 4], which BAUS members and beyond can learn from.

Finally, renal oncocytoma and its management may pose its own challenges as recorded by Neves et al. [5]. We also present the BAUS radical prostatectomy audit, which is publicly accessible and reassures readers (and the public) that the majority of these operations are being performed in high‐volume centres (164/centre) by high‐volume surgeons with good outcomes [6]. Nearly three in four operations are now performed robotically, which was certainly not the case when I started 15 years ago.

We look forward to meeting you at lunchtime on the Monday and Tuesday of the BAUS conference at the BJUI stand. I am particularly excited about the BJUI lecture and the National Clinical Entrepreneurship Programme, led by my friend Tony Young, on the second day of the meeting (https://www.baus.org.uk/agm/programme.aspx).

 

Prokar Dasgupta

MRC Centre for Transplantation, King’s College London, London, UK

 

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References

 

 

  • 2 Lucky M, Brown G, Dorkin T et al. British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies – testicular trauma. BJU Int 2018; 121: 840–4

 

  • 3 Wong KY, Jeeneea R, Healey A et al. Management of paediatric high‐grade blunt renal trauma: a 10‐year single‐centre UK experience. BJU Int 2018; 121: 923–7

 

  • 4 Hadjipavlou M, Grouse E, Gray R et al. Managing penetrating renal trauma: experience from two major trauma centres in the UK. BJU Int 2018; 121: 928–34

 

  • 5 Neves JB, Withington J, Fowler S et al. Contemporary surgical management of renal oncocytoma: a nation’s outcome. BJU Int 2018; 121: 893–9

 

  • 6 Khadhouri S, Miller C, Fowler S et al. The British Association of Urological Surgeons (BAUS) radical prostatectomy audit 2014/2015 – an update on current practice and outcomes by centre and surgeon case‐volume. BJU Int 2018; 121: 886–92

 

Article of the Week: Focal irreversible electroporation as primary treatment for localized prostate cancer

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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 the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and 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 week, it should be this one.

Focal irreversible electroporation as primary treatment for localized prostate cancer

 

Willemien van den Bos*†‡, Matthijs J. Scheltema*†‡, Amila R. Siriwardana*†, Anton M.F. Kalsbeek*, James E. Thompson†, Francis Ting*†, Maret Bohm*,
Anne-Maree Haynes*, Ron Shnier§, Warick Delprado¶ and Phillip D. Stricker†

 

*Garvan Institute of Medical Research and Kinghorn Cancer Centre, †St Vincent’s Prostate Cancer Centre, Darlinghurst, NSW, Australia, ‡Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands, §Southern Radiology, Randwick, and Douglass Hanly Moir Pathology, Macquarie Park, NSW, Australia

 

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Abstract

Objectives

To determine the safety, quality of life (QoL) and short‐term oncological outcomes of primary focal irreversible electroporation (IRE) for the treatment of localized prostate cancer (PCa), and to identify potential risk factors for oncological failure.

Patients and Methods

Patients who met the consensus guidelines on patient criteria and selection methods for primary focal therapy were eligible for analysis. Focal IRE was performed for organ‐confined clinically significant PCa, defined as high‐volume disease with Gleason sum score 6 (International Society of Urological Pathology [ISUP] grade 1) or any Gleason sum score of 7 (ISUP grades 2–3). Oncological, adverse event (AE) and QoL outcome data, with a minimum of 6 months’ follow‐up, were analysed. Patient characteristics and peri‐operative treatment variables were compared between patients with and without oncological failure on follow‐up biopsy. Wilcoxon’s signed rank test, Wilcoxon’s rank sum test and the chi‐squared test were used to assess statistically significant differences in paired continuous, unpaired continuous and categorical variables respectively.

Results

A total of 63 patients met all eligibility criteria and were included in the final analysis. No high‐grade AEs occurred. QoL questionnaire analysis demonstrated no significant change from baseline in physical (P = 0.81), mental (P = 0.48), bowel (P = 0.25) or urinary QoL domains (P = 0.41 and P = 0.25), but there was a mild decrease in the sexual QoL domain (median score 66 at baseline vs 54 at 6 months; P < 0.001). Compared with baseline, a decline of 70% in prostate‐specific antigen level (1.8 ng/mL, interquartile range 0.96–4.8 ng/mL) was seen at 6–12 months. A narrow safety margin (P = 0.047) and system errors (P = 0.010) were identified as potential early risk factors for in‐field oncological failure. In‐field and whole‐gland oncological control on follow‐up biopsies was 84% (38/45 patients) and 76% (34/45 patients); this increased to 97% (38/39 patients) and 87% (34/39 patients) when patients treated with a narrow safety margin and system errors were excluded.

Conclusion

Our data support the safety and feasibility of focal IRE as a primary treatment for localized PCa with effective short‐term oncological control in carefully selected men.

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Editorial: Has tailored, tissue‐selective tumour ablation in men with prostate cancer come of age?

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There are two principal challenges that face the growing number of clinical investigators that are evaluating tissue‐preserving therapies in men with prostate cancer.

The first is that every man’s prostate is different. So different and so unique are the personal attributes of a man’s prostate that it would, just like the iris or fingerprint, qualify as a unique identifier. It is just a few practical considerations that prevent it from doing so. This is a challenge that the clinician treating the liver, kidney or brain does not face – as these organs do not exhibit the between patient variability that we see in the prostate.

The second relates to within‐patient (or within‐prostate) differences. The nature of the tissue being treated will depend on which part of the prostate is being treated – peripheral, transition or central zone. Each of these zones will, in turn, be dependent on the age of the prostate, the extent of BPH, exhibit calcification and or cysts, and may or may not be infiltrated by acute and/or chronic inflammation.

These two sets of variability present considerable challenges to investigators that seek to selectively ablate a given zone of tissue, given that the nature of the target volume will be different in every man treated and exist in a context that is specific to the that man.

Add to this challenge the variability in prostate cancer tumour attributes – volume, location, heterogeneity (genetic, radiological, and histological), degree of immune infiltrate, and the extent of microscopic extension, we begin to get the picture 1.

The paper in this issue of the BJUI by van den Bos et al. 2 describes a modern attempt to overcome these challenges and attempt and achieve personalised care to individuals, their prostate glands, and their cancer.

The team used irreversible electroporation (IRE) to create a selective ablation zone around a given tumour volume, embracing a margin of 5–10 mm. This method of ablation has certain attributes that lend itself to the task. It can be applied to any zone of the prostate. It is not limited by the size of the prostate. It can create lesions of variable volume. The treatment is quick and therefore not overly affected by prostate gland swelling. Because the treatment uses an interstitial approach (needle based) the effectors of the treatment move with the prostate during respiration and changes in rectal fullness. These attributes mitigate most of the challenges generated by between‐patient variability.

The authors describe the methods by which they manage tumour‐specific differences. These important but rather technical constraints (to the non‐expert) comprise: tumour‐volume dependent variable needle load; individualised tissue impedance‐based energy adjustment; minimising variability in needle–needle distance; application of a 10‐mm margin; and near term verification of tissue change with post‐treatment MRI.

These conditions seem to have paid off. Although every patient underwent a treatment that was bespoke to both their prostate and their prostate cancer, the results were most promising for this truly personalised sub‐specialty of uro‐oncology.

The treatment was safe. There were no high‐grade adverse events reported in the 63 men included in the analysis. The disease‐specific and generic quality of life was not compromised by the range of interventions administered except in relation to the sexual quality of life domain that was marginally affected – a median score of 66 prior to therapy diminished to 54 when measured again 6‐months after treatment.

The authors managed to get a high proportion of men to undergo verification biopsy after treatment. From this they derived two oncological outcomes. These comprised freedom from clinically significant prostate cancer (high‐volume exclusive Gleason pattern 3 and/or any Gleason pattern 4 or 5) within and on the edge of field on the one hand and out of field on the other.

In patients who were free of any technical failure in relation to the administration of IRE and had a 10‐mm margin incorporated, the results were very promising with most of the patients evaluated free of disease both within (97% [38/39 men]) and out of field (87% [34/39 men]).

Although the numbers of patients reported upon are relatively small, the overall results represent a welcome improvement on previously published phase I clinical trial data using IRE, probably as a result of better patient selection and optimisation of energy delivery 3. The results, however, are reassuringly similar to previous case‐series that used alternative energy sources but were predicated on an anatomical‐based approach to tissue preservation 4. The tumour‐based approach reported upon by van den Bos et al. 2 is much more challenging as it exposes any subtle deficiencies in the base‐line risk‐stratification and imposes exacting constraints on the reliability of the energy source in creating irreversible cell kill where cell kill is intended.

Mark Emberton
Division of Surgery and Interventional Science, UCL, London, UK

 

Read the full article
References
  • 1 Linch M, Goh G, Hiley C et al. Intratumoural evolutionary landscape of high‐risk prostate cancer: the PROGENY study of genomic and immune parameters. Ann Oncol2017; 28: 2472–80

 

  • 2 van den Bos W, Scheltema MJ, Siriwardana AR et al. Focal irreversible electroporation as primary treatment for localized prostate cancer. BJU Int 2018; 121: 716–24

 

  • 3 Valerio M, Dickinson L, Ali A et al. Nanoknife electroporation ablation trial: a prospective development study investigating focal irreversible electroporation for localized prostate cancer. J Urol 2017; 197: 647–54

 

  • 4 Ahmed HU, Hindley RG, Dickinson L et al. Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study. Lancet Oncol 2012; 13: 622–32

 

Article of the Week: Multiple Growth Periods of SRMs Predict Unfavourable Pathology

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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 the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Multiple growth periods predict unfavourable pathology in patients with small renal masses

Alex Jang , Hiten D. Patel, Mark Riffon, Michael A. Gorin , Alice Semerjian, Michael H. Johnson, Mohamad E. Allaf and Phillip M. Pierorazio

 

Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA

 

Read the full article

Abstract

Objective

To use the number of positive growth periods as a characterization of the growth of small renal masses in order to determine potential predictors of malignancy.

Patients and Methods

Patients who underwent axial imaging at multiple time points prior to surgical resection for a small renal mass were queried. Patients were categorized based on their pathological tumour grade and stage: favourable (benign, chromophobe and low‐grade pT1–2 renal cell carcinoma [RCC]) vs unfavourable (high‐grade of any stage and low‐grade pT3–4 RCC). A positive growth period was counted each time the difference in greatest tumour diameters between two images was positive. The Cochran–Armitage trend test and Somers’ D association were used to determine if the number of positive growth periods was correlated with unfavourable pathology.

Results

Of the 124 patients, 86 (69.4%) had favourable pathology and 38 (30.6%) had unfavourable pathology. Those who had favourable pathology were younger than those who had unfavourable pathology: median (interquartile range [IQR]) 61.0 (52.2–66.0) vs 68.5 (61.5–77.0); P < 0.001. The overall growth rate was higher in the unfavourable group, but was not statistically significant: mean (sd) 0.7 (1.7) vs 1.6 (2.8) cm/year; P = 0.07. There was a significant trend difference in the number of positive growth periods between favourability groups (P = 0.02). An association between increased number of positive growth periods and unfavourable pathology was observed: 0.15 (95% confidence interval 0.02, 0.29). The ratios of favourable to unfavourable pathology were 1.8, 1.0, 0.66, 0.59 and 0 as the number of positive growth periods increased from 0 to 4, respectively.

Conclusion

While overall growth rate was not predictive of pathology favourability, there was a positive association between the number of positive growth periods and unfavourable pathology. The number of positive growth periods may be a potential parameter for malignant potential in patients undergoing active surveillance for small renal masses.

Read more articles of the week

Editorial: Growth spurts of small renal masses correlate with pathology

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A rapid growth rate has long been known to be a harbinger of aggressive tumour pathology and clinical behaviour of small renal masses (SRMs) 1. However, this association has not been confirmed in prospective studies of patients with SRMs on active surveillance (AS) 2. Jewett et al. 2, in a multicentre prospective phase 2 clinical trial of 209 patients with a SRM, found that despite an average growth rate of 0.13 cm/year, pathology did not impact growth. Clinically, the growth rates of SRMs are most commonly variable, rather than the assumed steady slow growing rate that is often reported 3. Due to the discrepancies in the literature, the use of average growth rate for a SRM can be misleading. Finding a clinically effective tool to identify potentially aggressive cancers remains an important (and unmet) need for patients undergoing AS.

Jang et al. 4 provide insight into this need by evaluating the number of growth periods over time as a risk factor for renal masses under surveillance. They retrospectively reviewed renal masses that were initially <4 cm at diagnosis and were followed for a variable time period before undergoing surgical therapy. Two cohorts were grouped into ‘favourable‐’ (benign tumours, chromophobe RCC and low grade, pT1–2 RCC) and ‘unfavourable’‐risk tumours (high‐grade RCC of any stage and low‐grade, pT3–4 RCC), finding no difference in the amount of interval imaging between the two groups. There was a significant difference in the number of positive growth periods between the ‘favourable’ and ‘unfavourable’ pathology groups (P = 0.02) for the entire cohort (all pT stages) and a similar finding when examining only pT1a tumours (P < 0.05). Additionally, there was a positive association between increased number of positive growth periods and unfavourable pathology (odds ratio 0.15, 95% CI 0.02–0.29).

Active surveillance is considered an acceptable initial option for the management of all patients with SRMs, not just those with limited life expectancy or poor performance, as highlighted in the 2017 AUA guidelines 5. Optimal management of patients on AS would appear to require a good understanding of growth kinetics, pathological details, and risk–benefit analysis. The previously held dogma of using linear growth rate as a guide for the aggressiveness of a tumour has been challenged recently 6 and again put into question by this study 4. The Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) study showed that there was a higher growth rate in patients who had delayed intervention compared with those on AS, but there was no significant association (P = 0.15) 6. However, in the same study, the proportion of patients who had a positive growth rate (>0 cm/year) or a recorded ‘growth spurt’ were significantly more likely to have delayed intervention than AS patients (P < 0.01) 6.

Growth spurts, rather than growth rate over time, as a marker for malignancy, correlates best with clinical experience. Average growth rate can be artificially high with one large growth and multiple stable imaging intervals. One of the important elements of AS is regular interval imaging. The development of protocols that can be evaluated to determine the optimal type, interval, and duration of follow‐up imaging is a clinical need in this space. Whilst the cohort from Jang et al. 4 did not have regular intervals for imaging, there were an equal number of studies performed on patients with ‘favourable’ and ‘unfavourable’ pathology. Without clear protocols, using growth spurts rather than growth rate, also provides a simplified message for patients and will aid in counselling.

The identification of growth spurts as a risk factor for potentially aggressive features of SRMs under surveillance provides a useful tool when determining the need for intervention of a SRM. The uniform reporting of pathological data for patients under study is a strength, but several weaknesses limit the generalisability of the findings including the retrospective study design and inconsistent manner in which AS was performed. The clinical impact of growth spurts in the AS population warrants further investigation before definitive conclusions can be drawn.

Conrad M. Tobert* and Brian R. Lane†‡
*Department of Urology, University of Iowa, Iowa City, IA, USA, †Division of Urology, Spectrum Health Medi cal Group, Grand Rapids, MI, USA and ‡Michigan State University College of Human Medicine, Grand Rapids, MI, USA

 

Read the full article
References
  • 1 Lee SW, Sung HH, Jeon HG et al. Size and volumetric growth kinetics of renal masses in patients with renal cell carcinoma. Urology 2016; 90: 119–24

 

 

  • 3 Chawla SN, Crispen PL, Hanlon AL, Greenberg RE, Chen DY, Uzzo RG. The natural history of observed enhancing renal masses: meta‐analysis and review of the world literature. J Urol 2006; 175: 425–31

 

  • 4 Jang A, Patel HD, Riffon M et al. Multiple growth periods predict unfavourable pathology in patients with small renal masses. BJU Int 2018; 121: 732–6

 

 

 

Video: Multiple Growth Periods of SRMs Predict Unfavourable Pathology

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Multiple growth periods predict unfavourable pathology in patients with small renal masses

 

Read the full article

Abstract

Objective

To use the number of positive growth periods as a characterization of the growth of small renal masses in order to determine potential predictors of malignancy.

Patients and Methods

Patients who underwent axial imaging at multiple time points prior to surgical resection for a small renal mass were queried. Patients were categorized based on their pathological tumour grade and stage: favourable (benign, chromophobe and low‐grade pT1–2 renal cell carcinoma [RCC]) vs unfavourable (high‐grade of any stage and low‐grade pT3–4 RCC). A positive growth period was counted each time the difference in greatest tumour diameters between two images was positive. The Cochran–Armitage trend test and Somers’ D association were used to determine if the number of positive growth periods was correlated with unfavourable pathology.

Results

Of the 124 patients, 86 (69.4%) had favourable pathology and 38 (30.6%) had unfavourable pathology. Those who had favourable pathology were younger than those who had unfavourable pathology: median (interquartile range [IQR]) 61.0 (52.2–66.0) vs 68.5 (61.5–77.0); P < 0.001. The overall growth rate was higher in the unfavourable group, but was not statistically significant: mean (sd) 0.7 (1.7) vs 1.6 (2.8) cm/year; P = 0.07. There was a significant trend difference in the number of positive growth periods between favourability groups (P = 0.02). An association between increased number of positive growth periods and unfavourable pathology was observed: 0.15 (95% confidence interval 0.02, 0.29). The ratios of favourable to unfavourable pathology were 1.8, 1.0, 0.66, 0.59 and 0 as the number of positive growth periods increased from 0 to 4, respectively.

Conclusion

While overall growth rate was not predictive of pathology favourability, there was a positive association between the number of positive growth periods and unfavourable pathology. The number of positive growth periods may be a potential parameter for malignant potential in patients undergoing active surveillance for small renal masses.

Read more articles of the week

Article of the Week: More PLND template at RP detects metastases in the common iliac region and in the fossa of Marcille

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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 the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and 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 week, it should be this one.

More extended lymph node dissection template at radical prostatectomy detects metastases in the common iliac region and in the fossa of Marcille

 

Lydia Maderthaner, Marc A. Furrer, Urs E. Studer, Fiona C. Burkhard, George N. Thalmann and Daniel P. Nguyen

 

Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
Read the full article

 

Abstract

Objectives

To assess the effect of adding lymph nodes (LNs) located along the common iliac vessels and in the fossa of Marcille to the extended pelvic LN dissection (PLND) template at radical prostatectomy (RP).

Patients and Methods

A total of 485 patients underwent RP and PLND at a referral centre between 2000 and 2008 (historical cohort: classic extended PLND template) and a total of 268 patients between 2010 and 2015 (contemporary cohort: extended PLND template including LNs located along the common iliac vessels and in the fossa of Marcille). Descriptive analyses were used to compare baseline, pathological, complication and functional data between the two cohorts. A logistic regression model was used to assess the template’s effect on the probability of detecting LN metastases.

Results

Of 80 patients in the historical cohort with pN+ disease, the sole location of metastasis was the external iliac/obturator fossa in 23 (29%), and the internal iliac in 18 (23%), while 39 patients (49%) had metastases in both locations. Of 72 patients in the contemporary cohort with pN+ disease, the sole location of metastasis was the external iliac/obturator fossa in 17 patients (24%), the internal iliac in 24 patients (33%), and the common iliac in one patient (1%), while 30 patients (42%) had metastases in >1 location (including fossa of Marcille in five patients). Among all 46 patients in the contemporary cohort with ≤2 metastases, three had one or both metastases in the common iliac region or the fossa of Marcille. The adjusted probability of detecting LN metastases was higher, but not significantly so, in the contemporary cohort. There were no differences between the two cohorts in complication rates and functional outcomes.

Conclusion

A more extended template detects LN metastases in the common iliac region and the fossa of Marcille and is not associated with a higher risk of complications; however, the overall probability of detecting LN metastases was not significantly higher.

Read more articles of the week

 

Editorial: PLND during RP for PCa: extending the template in the right patients without increasing complications

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It took long time and consistent evidence to endorse the staging role of extended pelvic lymph node dissection (PLND) in prostate cancer (PCa). The poor performance of both conventional and functional imaging in identifying preoperative nodal status has contributed to making extended PLND the most accurate nodal staging procedure in PCa 1.

Current available guidelines recommend a standard extended PLND template that includes external, internal iliac and obturator lymph nodes 2–4; however, where does the need for a more extended template originate? Observational data suggest that a standard extended PLND template intercepts ~75% of all anatomical landing sites 4. Extending the anatomical template by adding nearby nodal stations would further minimize the risk of missing positive lymph nodes; however, it has previously been shown that a more accurate staging (i.e. a more extended template) might come at the price of longer operating time and a higher risk of procedure‐related complications 1.

According to the study by Maderthaner et al. 5, in the current issue of BJUI, an experienced academic surgical team is able to further extend the PLND template (including common iliac and the fossa of Marcille lymph nodes) without significantly increasing the risk of complications. In their study, 17% and 7% of the included men with pN+ disease had positive common iliac and fossa of Marcille lymph nodes, respectively.

Before celebrating this super‐extended template as safe and effective, however, at least three points need to be considered. First, these results were obtained by a group of skilled surgeons with longstanding experience in anatomical pelvic nodal dissection. It should not be taken for granted that this template in the hands of other surgeons would result in no additional complications, especially during the learning curve.

Second, >80% of men submitted to the super‐extended template did not have positive nodes outside the standard extended template boundaries, indicating possible overtreatment in a substantial proportion of men. Notably, extended PLND in this study was offered apparently without upfront preoperative lymph node invasion risk stratification.

Third, as a consequence, patient selection has a role to play. In other words, is super‐extended PLND appropriate for every patient? The use of available risk stratification tools in everyday clinical practice allows a more accurate decision process; this is the case for the Briganti nomogram concerning the need to perform an extended PLND 6. Could a similar approach be used in the setting of a super‐extended template to identify the best candidates? Recently, Gandaglia et al. 7 analysed data from 471 men with high‐risk PCa treated with radical prostatectomy and a super‐extended PLND including common iliac and pre‐sacral nodes in order to identify those men who really require such a super‐extended PLND. Interestingly, although not specifically designed for this task, the Briganti nomogram was able to provide a patient selection strategy: only 5% of patients with a nomogram‐derived N+ risk of <30% had positive common iliac and pre‐sacral nodes, indicating that the super‐extended PLND template should perhaps be considered exclusively in men with an N+ risk ≥30%.

In conclusion, a critical assessment of super‐extended staging PLND template would be welcome, allowing selection of the proper candidates, and a proper balance between accurate staging and the risk of treatment‐related complications.

 

Eugenio Vent imiglia, *†Alberto Briganti,*† and Francesco Montorsi,*†
*University Vita-Salute San Raffaele, Milan, Italy and †Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy

 

Read the full article

 

References

 

  • 1 Fossati N, Willemse P‐PM, Van den Broeck T et al. The benefits and harms of different extents of lymph node dissection during radical prostatectomy for prostate cancer: a systematic review. Eur Urol 2017; 72: 84–109

 

  • 2 Santis D, Henry A, Joniau S et al. Prostate Cancer EAU ESTRO SIOG Guidelines on 2017.

 

  • 3 Mattei A, Fuechsel FG, Bhatta Dhar N et al. The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study. Eur Urol 2008; 53: 118–25

 

 

  • 5 Maderthaner L, Furrer MA, Studer UE, Burkhard FC, Thalmann GN, Nguyen DP. More extended lymph node dissection template at radical prostatectomy detects metastases in the common iliac region and in the fossa of Marcille. BJU Int 2018; 121: 725–31

 

  • 6 Briganti A, Larcher A, Abdollah F et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 2012; 61: 480–7

 

  • 7 Gandaglia G, Zaffuto E, Fossati N et al. Identifying the candidate for super extended staging pelvic lymph node dissection among patients with high‐risk prostate cancer. BJU Int 2018; 121: 421–7

 

Article of the Month: The Metabolic Syndrome & the Prostate

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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 the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and 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 week, it should be this one.

Association between metabolic syndrome and intravesical prostatic protrusion in patients with benign prostatic enlargement and lower urinary tract symptoms (MIPS Study)

Giorgio I. Russo*, Federica Regis*, Pietro Spatafora†, Jacopo Frizzi†, Daniele Urzı*, Sebastiano Cimino*, Sergio Serni†, Marco Carini†, Mauro Gacci† and Giuseppe Morgia*

 

*Urology Section, Department of Surgery, University of Catania, Catania, Italy, and †Department of Urology, University of Florence, Florence, Italy

 

Read the full article

Abstract

Objective

To investigate the association between metabolic syndrome (MetS) and morphological features of benign prostatic enlargement (BPE), including total prostate volume (TPV), transitional zone volume (TZV) and intravesical prostatic protrusion (IPP).

Patients and Methods

Between January 2015 and January 2017, 224 consecutive men aged >50 years presenting with lower urinary tract symptoms (LUTS) suggestive of BPE were recruited to this multicentre cross‐sectional study. MetS was defined according to International Diabetes Federation criteria. Multivariate linear and logistic regression models were performed to verify factors associated with IPP, TZV and TPV.

Results

Patients with MetS were observed to have a significant increase in IPP (P < 0.01), TPV (P < 0.01) and TZV (P = 0.02). On linear regression analysis, adjusted for age and metabolic factors of MetS, we found that high‐density lipoprotein (HDL) cholesterol was negatively associated with IPP (r = −0.17), TPV (r = −0.19) and TZV (r = −0.17), while hypertension was positively associated with IPP (r = 0.16), TPV (r = 0.19) and TZV (r = 0.16). On multivariate logistic regression analysis adjusted for age and factors of MetS, hypertension (categorical; odds ratio [OR] 2.95), HDL cholesterol (OR 0.94) and triglycerides (OR 1.01) were independent predictors of TPV ≥ 40 mL. We also found that HDL cholesterol (OR 0.86), hypertension (OR 2.0) and waist circumference (OR 1.09) were significantly associated with TZV ≥ 20 mL. On age‐adjusted logistic regression analysis, MetS was significantly associated with IPP ≥ 10 mm (OR 34.0; P < 0.01), TZV ≥ 20 mL (OR 4.40; P < 0.01) and TPV ≥ 40 mL (OR 5.89; P = 0.03).

Conclusion

We found an association between MetS and BPE, demonstrating a relationship with IPP.

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Editorial: The metabolic syndrome and the prostate

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The metabolic syndrome has been known for ~80 years 1 and is important to both urologists and their patients because of a two‐fold increase in the relative risk of atherosclerotic cardiovascular disease‐related events and a five‐fold increase for developing Type 2 diabetes as compared to people without the syndrome. Abdominal obesity is well known to be an important underlying risk factor for precipitating the syndrome and obesity is also known to markedly increase the risk for developing BPH and its symptoms 2. There are other associations that may be relevant here including an association between a lack of physical activity and the severity of LUTS 3, and a close correlation between the degree of prostatic and systemic inflammation and the degree of LUTS 4. Systemic inflammation is implicated in the metabolic syndrome with pro‐inflammatory cytokines due to the adipose tissue load, such as C‐reactive protein, tumour necrosis factor α and interleukin 6, being involved in causing the insulin resistance, which is a diagnostic feature of this condition 5.

The current study connects the metabolic syndrome with an anatomical feature of benign prostatic enlargement (BPE), namely intravesical prostatic protrusion (IPP) 6. Each of the diagnostic features of metabolic syndrome was examined separately such as reduced high‐density lipoprotein (HDL)‐cholesterol and raised triglycerides. Hypertriglyceridaemia is due to an overproduction of very‐low‐density lipoprotein (VLDL) by the liver and a reduction of lipoprotein lipase in peripheral tissues, and reflects the insulin resistant condition responsible for the metabolic syndrome 5. In this study, high triglyceride levels were an independent predictor of a total prostatic volume (TPV) of >40 mL. The other major lipoprotein abnormality in metabolic syndrome is a reduction in HDL‐cholesterol levels, which is due to both a decrease in the cholesterol content of this lipoprotein and an increase in its clearance from the circulation. In this study by Russo et al. 6, HDL levels were negatively associated with IPP and both total and transition zone volumes, and they postulate that these associations may be mediated by the effect of dyslipidaemia on prostate cells and prostatic inflammation.

Hypertension is another diagnostic feature that the authors address. There is increased renal sodium reabsorption, increased activity of the sympathetic nervous system, and vasoconstriction related to an increase in fatty acids in this syndrome. Hypertension, defined as systolic ≥135 mmHg, diastolic ≥85 mmHg or on current treatment, was positively associated with IPP and also associated with a TPV of ≥40 mL and a transitional zone volume of ≥20 mL in this study 6. Waist circumference and fasting glucose were not as strongly related to the features of BPH but ultimately are key drivers of the metabolic syndrome and management of these features is a cornerstone of the management of the whole condition.

Lifestyle and dietary interventions can address many of the aspects of this insulin‐resistant state with medical management of the metabolic features being used to supplement these. The same interventions are also successful in decreasing LUTS 3, which should not be surprising given the above. The longstanding aphorism that ‘heart healthy is prostate healthy’ appears to not only apply to the treatment of prostate cancer but also to that of BPH and urologists remain in an important position to identify men at significant risk.

Peter J. Gilling
Urology, Bay of Plenty District Health Board Clinical School, Tauranga, New Zealand

 

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References
  • 1 Alberti KG, Zimmet P, Shaw J, IDF Epidemiology Task Force Consensus Group. The metabolic syndrome–a new worldwide definition. Lancet 2005; 366: 1059–62

 

  • 2 Parsons JK, Sarma AV, McVary K, Wei JT. Obesity and benign prostatic hyperplasia: clinical connections, emerging etiological paradigms and future directions. J Urol 2013; 189 (Suppl.): S102–6.

 

  • 3 Fowke JH, Phillips S, Koyama T et al. Association between physical activity, lower urinary tract symptoms (LUTS) and prostate volume. BJU Int 2013; 111: 122–8

 

  • 4 Burris MB, Cathro HP, Kowalik CG et al. Lower urinary tract symptom improvement after radical prostatectomy correlates with degree of prostatic inflammation. Urology 2014; 83: 186–90

 

  • 5 Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet 2005; 365: 1415–28

 

  • 6 Russo GI, Regis F, Spatafora P et al. Association between metabolic syndrome and intravesical prostatic protrusion in patients with benign prostatic enlargement and lower urinary tract symptoms (MIPS Study). BJU Int 2018; 121: 799–804.

 

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