Statin Concentration in Prostatic Tissue is Subtype- and Dose-dependent.

OBJECTIVE: To evaluate for the first time, comparative serum and prostate tissue concentrations of lipophilic and hydrophilic statins. METHODS: After reviewing all patients who underwent radical prostatectomy between 1993 and 2019, we selected 80 patients taking atorvastatin (lipophilic) or rosuvastatin (hydrophilic) for cholesterol control and with available banked fresh-frozen tissue from the prostatectomy. Primary endpoint was serum and prostate statin concentration measured by HPLC-mass spectrometry analysis. Serum/prostate statin concentrations were compared between patients on atorvastatin and rosuvastatin, and patients receiving high- and low-dose statin, using the Mann-Whitney U test. RESULTS: In total, 39 patients were taking atorvastatin and 41 were taking rosuvastatin. Thirty-eight and 42 were taking high- and low-dose statin, respectively. Statin concentration was measurable in the prostatic tissue of 15 patients (38.4%) taking atorvastatin (33.3% high-dose vs 42.8% low-dose) compared to 22 (53.6%) taking rosuvastatin (55% high-dose vs 52.3% low-dose). Median tissue concentration of rosuvastatin was greater than atorvastatin (3.98 ng/g vs 0.96 ng/g, P <.001). Dose-dependency was observed: median prostate concentration was higher in those taking high-dose versus low-dose statin for both atorvastatin (1.22 ng/g vs 0.79 ng/g, P = .69) and rosuvastatin (5.21 ng/g vs 1.99 ng/g, P <.001). CONCLUSION: We have shown, for the first time, that lipophilic and hydrophilic statins can be measured in the prostate of patients with prostate cancer and that the concentrations are dependent on dose. Moreover, rosuvastatin, a hydrophilic statin, achieves a 4-fold higher concentration in the prostate.

5-α Reductase Inhibitors and Prostate Cancer Mortality.

Importance: 5-alpha-reductase-inhibitors (5-ARIs) are approved for treating benign prostatic hyperplasia (BPH) and have been found to reduce prostate cancer (PCa) risk by 25%. However, trials also have shown 5-ARIs to be associated with high-grade PCa. Whether 5-ARIs increase mortality among those with a diagnosis of PCa remains unclear. Objective: To determine long-term outcomes of clinically localized PCa arising in individuals taking 5-ARIs compared with nonusers. Design, Setting, and Participants: This population-based cohort study was conducted between January 2003 and October 2017. Eligible participants were men aged 65 years or older in Ontario, Canada, who developed clinically localized PCa with complete pathological abstraction from the Ontario Health Administrative Databases. Data analysis occurred from November 2017 to November 2022. Exposure: 5-ARIs before PCa diagnosis. Main Outcomes and Measures: The primary outcomes were overall mortality and PCa-specific mortality. Cause-specific hazard models with inverse probability treatment weights (IPTW) were used to examine associations of 5-ARI use with mortality outcomes. Sensitivity analyses based on prediagnostic 5-ARI use, Gleason score, comorbidity, 5-ARI indication, prostate-specific antigen modeling, and statin use were also performed. Results: The cohort included 19 938 patients with PCa. Of these, 2112 (10.6%; median [IQR] age, 74 [70-79] years) were 5-ARI users and 17 826 (89.4%; median [IQR] age, 71 [68-76] years) were nonusers. During a median (IQR) follow-up of 8.96 (6.28-12.17) years, 6053 (30.4%) died, including 1047 (5.3%) from PCa. 5-ARI use appeared to be associated with increased overall and PCa specific mortality in crude analyses; however, after IPTW, 5-ARI use was not associated with overall mortality (hazard ratio, 0.98; 95% CI, 0.90-1.07; P = .77) or PCa-specific mortality (hazard ratio, 1.02; 95% CI, 0.83-1.25; P = .84). Conclusions and Relevance: In this population-based cohort study of 5-ARI use prior to PCa diagnosis including long-term follow-up and clinicopathologic details, prediagnostic 5-ARI use was not associated with PCa-specific or all-cause mortality. This study offers reassuring safety data for patients using 5-ARIs before PCa diagnosis for both BPH and chemopreventive reasons.

Lymph node density as a prognostic marker of relapse in patients who underwent primary retroperitoneal lymph node dissection.

INTRODUCTION: Primary retroperitoneal lymph node dissection (pRPLND) is a treatment option for clinical stage (CS) II testicular germ cell tumors (TGCTs) and CS I with retroperitoneal relapse. Increasing raw lymph node yield during pRPLND has been associated a decreased relapse risk. However, this metric has limitations due to variations in surgical templates and specimen processing methods. We aimed to evaluate the lymph node density (LND), which is the ratio of positive lymph nodes to the total number of nodes removed, as a prognostic marker for relapse after pRPLND. METHODS: We reviewed all patients who underwent pRPLND at the Princess Margaret Cancer Centre between 1990 and 2022. The primary endpoint was relapse-free survival (RFS). RFS was calculated using the Kaplan-Meier product-limit method. The log-rank test was used to assess the impact of LND, and recursive binary partitioning was used to determine the threshold LND that provides optimum separation in RFS. RESULTS: In this study, 178 patients were treated with pRPLND. A total of 137 (77%) patients had pathological evidence of nodal metastasis, 96 were treated with open RPLND, and 41 with robotic RPLND. The median number of lymph nodes harvested was 32 (IQR 23-43) and median total positive nodes was 2 (IQR 1-36). This translated into a median LND of 3.1% (IQR 1.7-57.1). There was no significant difference in the LND between robotic and open approaches (P = 0.6664). After a median follow-up of 38.6 months, 11 patients (8.02%) had relapsed. LND was not significantly associated with relapse (HR 1.018, 95% CI, 0.977-1.061). The optimal threshold to dichotomize LND that provides optimum separation in RFS was ≥ 26.75%, however, it did not reach statistical significance (P = 0.0651). CONCLUSION: In conclusion, the LND was not associated with RFS after pRPLND in patients with TGCTs. The unique characteristics of TGCTs and the presence of other established risk factors limit the utility of the LND alone in predicting relapse.

Adjuvant immune checkpoint inhibitors for urothelial carcinoma: systematic review and Meta-analysis.

PURPOSE: To compare disease-free survival (DFS), overall survival (OS), and adverse events (AEs) among muscle-invasive urothelial carcinoma (MIUC) patients receiving adjuvant immune checkpoint inhibitors (ICIs) versus placebo/observation following radical surgery. METHODS: This was a systematic review/meta-analysis of all published phase 3 randomized controlled trials. MEDLINE, EMBASE, and Cochrane were searched from inception until April 4, 2024. Pooled hazard ratios (HR) and relative risks (RR), plus confidence intervals (CI), were generated using frequentist random-effects modeling. RESULTS: Three trials were identified: IMvigor010, CheckMate 274, and AMBASSADOR. In the overall cohort, adjuvant ICIs significantly improved DFS by 23% (HR = 0.77, 95% CI = 0.65-0.90). No DFS benefit was observed in patients with upper tract disease (HR = 1.19, 95% CI = 0.86-1.64). The highest magnitude of DFS benefit was observed among patients who had received prior neoadjuvant chemotherapy (HR = 0.69) and pathologic node-positive disease (HR = 0.75). A similar DFS benefit was observed irrespective of tumor PD-L1 status. Pooled OS demonstrated a 13% non-significant benefit (HR = 0.87, 95% CI = 0.75-1.01). Grade ≥ 3 immune-mediated AEs occurred in 8.6% and 2.1% of ICI and placebo/observation patients, respectively (RR = 4.35, 95% CI = 1.02-18.5). AEs leading to treatment discontinuation occurred in 14.3% and 0.9% of patients, respectively. CONCLUSION: Adjuvant ICIs confer a DFS benefit following radical surgery for MIUC, particularly among node-positive patients and those who received prior neoadjuvant chemotherapy. The lack of benefit for upper tract disease suggests that alternate adjuvant approaches, including chemotherapy, should be considered for these patients. Tumor PD-L1 status is not a predictive biomarker, highlighting the need for biomarkers in this setting.

Propensity-matched Analysis of Open Versus Robotic Primary Retroperitoneal Lymph Node Dissection for Clinical Stage II Testicular Cancer.

BACKGROUND: Open retroperitoneal lymph node dissection (O-RPLND) is the accepted standard surgical approach to treat retroperitoneal nodal disease in testis cancer. Increasingly, robotic RPLND (R-RPLND) is being performed due to the potential for lower blood loss, shorter length of stay, and accelerated recovery. OBJECTIVE: We have performed a propensity score matching (PSM) analysis comparing the survival and perioperative outcomes of O- and R-RPLND. DESIGN, SETTING, AND PARTICIPANTS: Analyzing the data from all patients who underwent primary RPLND at our center between 1990 and 2022, we used PSM to create a 2:1 (O-RPLND:R-RPLND) matched cohort. INTERVENTION: Primary O-RPLND versus R-RPLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was time to relapse. The secondary endpoints included operating time, length of stay, estimated blood loss (EBL), and surgical complications. Relapse-free survival rates were calculated using the Kaplan-Meier method, and log-rank tests were used to compare perioperative outcomes of O-RPLND versus R-RPLND. KEY FINDINGS AND LIMITATIONS: A total of 178 patients underwent primary RPLND: 137 O-RPLND and 41 R-RPLND. After PSM, 26 patients in the R-RPLND group were matched with 38 in the O-RPLND group. After matching, no significant baseline differences were noted. After a median follow-up of 23.5 mo (interquartile range 4.4-59.2), one (3.8%) relapse was noted in the R-RPLND group versus three (7.8%) in the O-RPLND group; however, this was not significant (hazard ratio 0.65, 95% confidence interval 0.07-6.31, p = 0.7097). No in-field relapses occurred in either cohort. R-RPLND was associated with a shorter length of stay (1 vs 5 d, p < 0.0001) and lower EBL (200 vs 300 ml, p = 0.032), but longer operative time (8.8 vs 4.3 h, p < 0.0001). CONCLUSIONS: R-RPLND offers low morbidity and improved perioperative outcomes, while maintaining oncologic efficacy of the open approach. PATIENT SUMMARY: To the best of our knowledge, this is the first study to compare open and robotic retroperitoneal lymph node dissection (R-RPLND) using a propensity score-matched system. We encourage the discussion and inclusion of primary R-RPLND into the standard of care algorithm for patients with de novo clinical stage (CS) II and relapsed CS I with CS II equivalent disease.

Limitations of Prostate Biopsy in Detection of Cribriform and Intraductal Prostate Cancer.

BACKGROUND: The presence of cribriform morphology and intraductal carcinoma (IDC) in prostate biopsies and radical prostatectomy specimens is an adverse prognostic feature that can be used to guide treatment decisions. OBJECTIVE: To assess how accurately biopsies can detect cribriform morphology and IDC cancer by examining matched biopsy and prostatectomy samples. DESIGN, SETTING, AND PARTICIPANTS: Patients who underwent radical prostatectomy at The Princess Margaret Cancer Centre between January 2015 and December 2022 and had cribriform morphology and/or IDC in the surgical specimen were included in the study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used detection sensitivity to evaluate the level of agreement between biopsy and prostatectomy samples regarding the presence of cribriform morphology and IDC. RESULTS AND LIMITATIONS: Of the 287 men who underwent radical prostatectomy, 241 (84%) had cribriform morphology and 161 (56%) had IDC on final pathology. The sensitivity of prostate biopsy, using radical prostatectomy as the reference, was 42.4% (95% confidence interval [CI] 36-49%) for detection of cribriform morphology and 44.1% (95% CI 36-52%) for detection of IDC. The sensitivity of prostate biopsy for detection of either IDC or cribriform morphology was 52.5% (95% CI 47-58%). Among patients who underwent multiparametric magnetic resonance imaging-guided biopsies, the sensitivity was 54% (95% CI 39-68%) for detection of cribriform morphology and 37% (95% CI 19-58%) for detection of IDC. CONCLUSIONS: Biopsy has low sensitivity for detecting cribriform morphology and IDC. These limitations should be incorporated into clinical decision-making. Biomarkers for better detection of these histological patterns are needed. PATIENT SUMMARY: Prostate biopsy is not an accurate method for detecting two specific types of prostate cancer cells, called cribriform pattern and intraductal prostate cancer, which are associated with unfavorable prognosis.

Long-term outcomes and cost savings of office fulguration of papillary Ta low-grade bladder cancer.

OBJECTIVES: To assess whether office-based fulguration (OF) under local anaesthesia for small, recurrent, pathological Ta low-grade (LG) non-muscle-invasive bladder cancer (NMIBC) is an effective alternative to transurethral resection of bladder tumour (TURBT), avoiding the costs and risks of procedure, and anesthesia. PATIENTS AND METHODS: Of 521 patients with primary TaLG NMIBC, this retrospective study included 270 patients who underwent OF during follow-up for recurrent, small, papillary LG-appearing tumours at a university centre (University Health Network, University of Toronto, Canada). We assessed the cumulative incidence of cancer-specific mortality (CSM) and disease progression (to MIBC or metastases), as well as possible direct cost savings. RESULTS: In the 270 patients with recurrent TaLG NMIBC treated with OF, the mean (sd) age was 64.9 (13.3) years, 70.8% were men, and 60.3% had single tumours. The mean (sd, range) number of OF procedures per patient was 3.1 (3.2, 1-22). The median (interquartile range) follow-up was 10.1 (5.8-16.2) years. Patients also underwent a mean (sd) of 3.6 (3.0) TURBTs during follow-up in case of numerous or bulkier recurrence. In all, 44.4% of patients never received intravesical therapy. The 10-year incidence of CSM and progression were 0% and 3.1% (95% confidence interval 0.8-5.4%), respectively. Direct cost savings in Ontario were estimated at $6994.14 (Canadian dollars) per patient over the study follow-up. CONCLUSIONS: This study supports that properly selected patients with recurrent, apparent TaLG NMIBC can be safely managed with OF under local anaesthesia with occasional TURBT for larger or numerous recurrent tumours, without compromising long-term oncological outcomes. This approach could generate substantial cost-saving to healthcare systems, is patient-friendly, and could be adopted more widely.

Poly(adenosine diphosphate-ribose) polymerase inhibitor combinations in first-line metastatic castrate-resistant prostate cancer setting: a systematic review and meta-analysis.

OBJECTIVES: To compare radiographic progression-free survival (rPFS), overall survival (OS), and treatment-emergent adverse events (TEAEs) among patients with metastatic castrate-resistant prostate cancer (mCRPC) receiving a combination of first-line poly(adenosine diphosphate-ribose) polymerase inhibitors (PARPi) plus androgen receptor axis-targeted agents (ARAT) vs placebo/ARAT. MATERIALS AND METHODS: We conducted a systematic review/meta-analysis of all published Phase III randomised controlled trials using EMBASE, MEDLINE, and Cochrane (inception until 6 June 2023). Published full-text manuscripts and conference abstracts were inclusion eligible. Study selection/data extraction were independently performed by two authors. The Cochrane Risk-of-Bias 2 Tool was used, and certainty of evidence assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework. Pooled hazard ratios (HRs) and relative risks, with corresponding confidence intervals (CIs), were generated using random-effects models. RESULTS: Three trials were identified: PROpel, MAGNITUDE, and TALAPRO-2. Compared to placebo/ARAT, the PARPi/ARAT combination was associated with a 35% rPFS improvement in the overall cohort (HR 0.65, 95% CI 0.56-0.76), with 68%, 45%, and 26% improvements in the BReast CAncer gene 1/gene 2 (BRCA1/2)-mutated (BRCA1/2m; P < 0.001), homologous recombination repair-mutated (HRRm; P < 0.001), and non-HRRm cohorts (P = 0.003), respectively. OS data maturity ranged from 31% to 48%, with overall cohort OS data unavailable from MAGNITUDE. The PROpel/TALAPRO-2 pooled analysis demonstrated a 16% OS improvement in the overall cohort (HR 0.84, 95 CI 0.72-0.98; P = 0.02). OS in the HRRm (HR 0.76, 95% CI 0.61-0.95) and the BRCA1/2m cohorts (HR 0.53, 95% CI 0.18-1.56) were improved, with a higher effect magnitude compared to the overall cohort. This combination was associated with a 45% relative risk increase in Grade ≥3 TEAEs, including 6.22-fold for Grade ≥3 anaemia (31.9% vs 4.9%). CONCLUSIONS: The addition of PARPi to ARAT in the first-line mCRPC setting is associated with rPFS benefits across subgroups, with the greatest magnitude of benefit in BRCA1/2m patients. OS benefits remain inconsistent irrespective of HRRm status, with significant increases in Grade ≥3 TEAEs, particularly anaemia. Currently, we suggest this combined approach be selectively offered to HRRm patients, preferentially BRCA1/2m.

Guideline of guidelines: follow-up after orchidectomy for clinical stage 1 testicular cancer.

Several medical organisations have developed evidence-based guidelines for the diagnosis, management, and follow-up of testicular cancer. This article aimed to review, compare, and summarise the most updated international guidelines and surveillance protocols for clinical stage 1 (CS1) testicular cancer. We reviewed a total of 46 articles on proposed follow-up strategies for testicular cancer, and six clinical practice guidelines including four guidelines published by urological scientific associations and two guidelines published by medical oncology associations. Most of these guidelines have been developed by panels of experts with different backgrounds in clinical training, and geographic practise patterns, which explains the considerable variability between published schedules, and recommended follow-up intensity. We present you with a comprehensive review of the most important clinical practice guidelines and propose unifying recommendations based on the most up to date evidence to help standardise follow-up schedules based on patterns and risk of disease relapse.

Small Testicular Masses: Contemporary Diagnostic and Treatment Strategies, Future Directions, and Knowledge Gaps.

The incidental discovery of small masses in the testicles of young men is becoming an increasing clinical dilemma. We are learning that the malignancy rate in masses ≤ 2 cm is much lower than traditionally thought and could be as low as 13% to 21%. The challenge remains in identifying which of these patients harbor malignant tumors that need to be treated, and benign lesions that could be safely surveilled. The aim of this narrative review is to discuss the current scientific evidence, diagnostic work-up, and treatment strategies for small testicular masses. We also discuss selection criteria, follow-up schedules and triggers for intervention for the surveillance of these small testis masses. Furthermore, we give a set of recommendations for assessing and treating these patients, based on the available literature and our experience at a dedicated testicular cancer clinic.

Small Renal Masses: The Evolving Histologic, Imaging, and Genomic Landscapes.

According to the American Cancer Society, it is currently estimated that approximately 81,800 new cases of kidney cancer will be diagnosed in the United States in 2023 [...].

Combined Reporting of Surgical Quality and Cancer Control after Surgical Treatment for Penile Tumors with Inguinal Lymph Node Dissection: The Tetrafecta Achievement.

BACKGROUND: To optimize results reporting after penile cancer (PC) surgery, we proposed a Tetrafecta and assessed its ability to predict overall survival (OS) probabilities. METHODS: A purpose-built multicenter, multi-national database was queried for stage I-IIIB PC, requiring inguinal lymphadenectomy (ILND), from 2015 onwards. Kaplan-Meier (KM) method assessed differences in OS between patients achieving Tetrafecta or not. Univariable and multivariable regression analyses identified its predictors. RESULTS: A total of 154 patients were included in the analysis. The 45 patients (29%) that achieved the Tetrafecta were younger (59 vs. 62 years; p = 0.01) and presented with fewer comorbidities (ASA score ≥ 3: 0% vs. 24%; p < 0.001). Although indicated, ILND was omitted in 8 cases (5%), while in 16, a modified template was properly used. Although median LNs yield was 17 (IQR: 11-27), 35% of the patients had <7 nodes retrieved from the groin. At Kaplan-Maier analysis, the Tetrafecta cohort displayed significantly higher OS probabilities (Log Rank = 0.01). Uni- and multivariable logistic regression analyses identified age as the only independent predictor of Tetrafecta achievement (OR: 0.97; 95%CI: 0.94-0.99; p = 0.04). CONCLUSIONS: Our Tetrafecta is the first combined outcome to comprehensively report results after PC surgery. It is widely applicable, based on standardized and reproducible variables and it predicts all-cause mortality.

miRNAs for testicular germ cell tumours: Contemporary indications for diagnosis, surveillance and follow-up.

Despite excellent outcomes with modern multidisciplinary care, clinicians caring for patients with testicular germ cell tumour (TGCTs) face clinical dilemmas across the spectrum of disease. Wrong treatment choices can lead to undertreatment or overtreatment of these young men. Unfortunately the currently available biomarkers alpha-fetoprotein and human chorionic gonadotropin, lack sufficient sensitivity and specificity to reliably aid in these clinical dilemmas. Thus, a sensitive and specific biomarker is desperately needed. Serum or plasma miRNA, in particular, miR-371a-3p, has shown great promise in discriminating the presence of TGCT and may represent a breakthrough for this disease. In this review, we discuss the potential role of miRNA across clinical states of TGCTs. We review their discovery, methods of assay, limitations and future potential.

Do We Need a Urine Culture Before Cystoscopy? Time to Shift Away from Routine Testing.

OBJECTIVE: To determine if cystoscopy could be safely performed without a urine culture by analyzing 2 prospectively cohorts of patients undergoing outpatient cystoscopy, 1 without urine culture and the other cohort screened and treated for ASB as per protocol. We aim to report the rate of symptomatic UTI and the rate of urinary sepsis within 30 days of cystoscopy. METHODS: All patients who underwent cystoscopy between 2021 and 2022 were invited to participate. Patients were prospectively recruited in a 2:1 ratio. Cohort A: patients who did not require urine culture before cystoscopy. Cohort B: patients who were required to have sterile urine before the procedure. Primary endpoint was the occurrence of symptomatic UTI ≤ 30 days after cystoscopy. RESULTS: A total of 461 patients were recruited, 316 for cohort A and 145 for cohort B. Fifteen patients had symptomatic UTIs between both groups, 8 in Cohort A and 7 in Cohort B. The overall rate of symptomatic UTI was 3.2%, 2.5% for Cohort A and 4.8% for Cohort B. We had only 1 case of urinary sepsis in Cohort B. The RR for developing UTI in cohort B was 1.91 in the univariate model and 1.74 in the multivariate analysis. CONCLUSION: Routine urine culture before outpatient cystoscopy is unnecessary. In asymptomatic patients, subsequent UTIs are rare and can be easily treated. Avoiding routine urine culture helps prevent misuse of antibiotics, reduce cancellation rates, and ease the burden of patients that get cancelled because of ASB. The low risk of symptomatic UTI after the procedure must be discussed with the patient.

Metastatic renal cell carcinoma of the native kidney in a renal transplant recipient: Revisiting the era of tyrosine kinase inhibitors - Case report.

Patients who receive solid organ transplants are at higher risk for developing cancer, which is attributable to chronic immune suppression. Less than 8 cases of metastatic RCC (mRCC) have been reported until now. The aim of this article is to present the case of a 77-year-old male with mRCC of the native kidney and discuss treatment options including targeted therapy, which appears to be the treatment of choice, even in the era of immunotherapy.

Inverted urethral flap reconstruction after partial penectomy: Long-term oncological and functional outcomes.

INTRODUCTION: Penile aesthetics after partial penectomy (PP) for penile cancer (PC), significantly affect a patient's health-related quality of life (HRQoL), self-esteem, and sexual function. Satisfactory reconstruction has become a major milestone in the treatment of these patients. METHODS: Clinical charts of all patients that underwent PP and reconstruction with an inverted urethral flap (IUF) were reviewed. The primary endpoints were recurrence-free survival (RFS), overall survival (OS), and progression-free survival (PFS) which were graphically represented by Kaplan-Meier estimates. The key secondary endpoints were Health-related quality of life (HRQoL), erectile function, and lower urinary tract symptoms. RESULTS: Between May 2007 and December 2019, 74 patients with PC underwent PP and IUF reconstruction. The median age was 62 years (IQR 52-76), median follow-up was 72 months (IQR 38-121). Twenty-nine patients (39.2%) underwent inguinal lymph node dissection, 62 (83.8%) underwent dynamic sentinel lymph node biopsy. Kaplan-Meier estimates of OS, RFS, and PFS showed a 6-year OS of 86.5%, 6-year RFS of 90.5%, and a 6-year PFS of 85.1%. Regarding functional outcomes, we found a mean global health score of 84.6% ± 10.4 at the EQ-5D-3L-VAS. The mean Voiding score of the ICIQ-MLUTS was 1.7 ± 3.2 and a mean IIEF-5 score of 17.3 ± 7. CONCLUSIONS: To the best of our knowledge, we report the largest cohort in the literature of PP with IUF reconstruction. These results are important since early-stage PC is the most common stage at diagnosis. In carefully selected patients' preservation of a longer urethral stump to allow for the inverted flap is safe and does not compromise oncological outcomes while preserving HRQoL.