Risk of secondary malignancy following radiation therapy for prostate cancer.

We investigated whether prostate cancer patients treated with external beam radiation therapy (EBRT) have a higher cumulative incidence of secondary cancer compared with patients treated with radical prostatectomy (RP). We used state-wide linked data from South Australia to follow men with prostate cancer diagnosed from 2002 to 2019. The cumulative incidence of overall and site-specific secondary cancers between 5 and 15 years after treatment was estimated. Fine-Gray competing risk analyses were performed with additional sensitivity analyses to test different scenarios. A total of 7625 patients were included (54% underwent RP and 46% EBRT). Characteristics of the two groups differed significantly, with the EBRT group being older (71 vs. 64 years), having higher comorbidity burden and being more likely to die during follow-up than the RP group. Fifteen-year cumulative incidence for all secondary cancers was 27.4% and 22.3% in EBRT and RP groups, respectively. In the adjusted models, patients in the EBRT group had a significantly higher risk of genitourinary (adjusted subhazard ratio (aSHR), 2.29; 95%CI 1.16-4.51) and lung (aSHR, 1.93; 95%CI 1.05-3.56) cancers compared with patients in the RP group. However, there was no statistically significant difference between the two groups for risk of any secondary cancer, gastro-intestinal, skin or haematologic cancers. No statistically significant differences in overall risk of secondary cancer were observed in any of the sensitivity analyses and patterns for risk at specific cancer sites were relatively consistent across different age restriction and latency/time-lag scenarios. In conclusion, the increased risk of genitourinary and lung cancers among men undergoing EBRT may relate partly to treatment effects and partly to unmeasured residual confounding.

Long term genitourinary toxicity following curative intent intensity-modulated radiotherapy for prostate cancer: a systematic review and meta-analysis.

BACKGROUND: Recent studies have shown that radiation-induced pelvic toxicity often requires urological consultation. However, the 10-year incidence of genitourinary toxicity following intensity-modulated radiotherapy (IMRT) amongst patients with localised prostate cancer remains unclear. Hence, we conducted a systematic review and meta-analysis to determine the incidence of late genitourinary toxicity relying on Radiation Therapy Oncology Group (RTOG) and Common Terminology Criteria for Adverse Events (CTCAE) grade as well as the incidence of specific genitourinary toxicity. Secondary objectives involved quantifing the number of studies reporting 120-month follow-up endpoints, time to event analysis, predictive factors or economic evaluation. METHODS: Articles published from January 2008 to December 2021 describing prospective studies were systematically searched in MEDLINE, EMBASE and Cochrane (PROSPERO protocol CRD42019133320). Quality assessment was performed by use of the Cochrane Risk of Bias 2 Tool for RCTs and the Newcastle Ottowa Scale for non-RCTs. Meta-analysis was performed on the 60-month incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity, haematuria, urinary retention and urinary incontinence. RESULTS: We screened 4721 studies and six studies met our inclusion criteria. All included studies involved normofractionation, three included a hypofractionation comparator arm and none involved nodal irradiation. The pooled 60-month cumulative incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity were 17% (95% CI: 5-20%, n = 678) and 33% (95% CI: 27-38%, n = 153), respectively. The pooled 60-month cumulative incidence of Haematuria was 5% (95% CI: -4-14%, n = 48), Urinary incontinence 12% (95% CI: 6-18%, n = 194), Urinary retention 24% (95% CI: 9-40%, n = 10). One study reported time to event analyses, one reported predictive factors, no studies reported economic analysis or 120-month toxicity. There was considerable heterogeneity amongst the studies. CONCLUSION: There are few high-quality studies reporting 60-month toxicity rates after IMRT. Conservative estimates of 60-month toxicity rates are high and there is need for longer follow-up and consistent toxicity reporting standards.

Predicting post-radiation genitourinary hospital admissions in patients with localised prostate cancer.

PURPOSE: The risk of treatment-related toxicity is important for patients with localised prostate cancer to consider when deciding between treatment options. We developed a model to predict hospitalisation for radiation-induced genitourinary toxicity based on patient characteristics. METHODS: The prospective South Australian Prostate Cancer Clinical Outcomes registry was used to identify men with localised prostate cancer who underwent curative intent external beam radiotherapy (EBRT) between 1998 and 2019. Multivariable Cox proportional regression was performed. Model discrimination, calibration, internal validation and utility were assessed using C-statistics and area under ROC, calibration plots, bootstrapping, and decision curve analysis, respectively. RESULTS: There were 3,243 patients treated with EBRT included, of which 644 (20%) patients had a treated-related admission. In multivariable analysis, diabetes (HR 1.35, 95% CI 1.13-1.60, p < 0.001), smoking (HR 1.78, 95% CI 1.40-2.12, p < 0.001), and bladder outlet obstruction (BOO) without transurethral resection of prostate (TURP) (HR 7.49, 95% CI 6.18-9.08 p < 0.001) followed by BOO with TURP (HR 4.96, 95% CI 4.10-5.99 p < 0.001) were strong independent predictors of hospitalisation (censor-adjusted c-statistic = 0.80). The model was well-calibrated (AUC = 0.76). The global proportional hazards were met. In internal validation through bootstrapping, the model was reasonably discriminate at five (AUC 0.75) years after radiotherapy. CONCLUSIONS: This is the first study to develop a predictive model for genitourinary toxicity requiring hospitalisation amongst men with prostate cancer treated with EBRT. Patients with localised prostate cancer and concurrent BOO may benefit from TURP before EBRT.

Pelvic Radiation Disease.

Pelvic radiation is increasingly being used for the neoadjuvant and definitive treatment of pelvic organ malignancy. While this treatment can be highly effective, and may assist in organ sparing, it is also associated with significant toxicity and devastating adverse events that need to be considered. In broad terms, pelvic radiation disease affects both the primary target organ as well as adjacent organs and soft tissue structures, with complications that can be classified and graded according to consensus criteria. The complication grade is often modality, dose, and area dependent. The most common manifestations are proctitis, cystitis, recto-urethral fistula, ureteric stricture, and bone involvement. Toxicity can be misdiagnosed for many years, resulting in significant management delays. Complications can be difficult to prevent and challenging to treat, requiring specialized multi-disciplinary input to achieve the best possible strategy to minimize impact and improve patient quality of life.

Incidence of genitourinary complications following radiation therapy for localised prostate cancer.

PURPOSE: Studies of genitourinary toxicity following radiotherapy for prostate cancer are mainly from high volume single institutions and the incidence and burden of treatment remain uncertain. Hence we determine the cumulative incidence of treatment-related genitourinary toxicity in patients with localised prostate cancer treated with primary external beam radiotherapy (EBRT) at a state population level. METHODS: We analysed data from a prospective population-based cohort, including hospital admission and cancer registry data, for men with localised prostate cancer who underwent primary EBRT without nodal irradiation between 1998 and 2019 in South Australia. The 10-year cumulative incidence of genitourinary toxicity requiring hospitalisation or procedures was determined. Clinical predictors of toxicity and the volume of admissions, non-operative, minor operative and major operative procedures were determined. RESULTS: All the included patients (n = 3350) had EBRT, with a median (IQR) of 74 Gy (70-78) in 37 fractions (35-39). The 10-year cumulative incidence of was 28.4% (95% CI 26.3-30.6) with a total of 2545 hospital admissions, including 1040 (41%) emergency and 1893 (74%) readmissions. The 10-year cumulative incidence of patients in this cohort requiring a urological operative procedure was 18% (95% CI 16.1-19.9), with a total of 106 (4.2%) non-operative, 1044 (41%) minor operative and 57 (2.2%) major operative urological procedures. CONCLUSIONS: Genitourinary toxicity after radiotherapy for prostate cancer is common. Although there continue to be advancements in radiotherapy techniques, patients and physicians should be aware of the risk of late toxicity when considering EBRT.

Valsalva leak point pressure (VLPP) greater than 70 cm H2O is an indicator for sling success: a success prediction model for the male transobturator sling.

INTRODUCTION AND OBJECTIVES: Urodynamic studies are often performed in the evaluation of post-prostatectomy urinary incontinence (PPUI). The male transobturator sling (TOS) is a minimally invasive treatment for PPUI. Others have reported their results with a specific Valsalva leak point pressure (VLPP) that predicts a good outcome with the male TOS. Our objective was to determine the relationship of the pre-operative VLPP on the success rate of the male TOS in a high-volume, single center. We hypothesized that a higher pre-operative VLPP better predicts successful outcomes. METHODS: We reviewed patients undergoing a male TOS placement from 2006 to 2012 at our institution. Patients who underwent TOS placement were identified using our patient data portal (DEDUCE). Demographic, urodynamic, and follow-up data were extracted by chart review. Post-operative success was defined by the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g per 24 h. Cox and linear regression models were performed. RESULTS: 290 patients were included. All patients underwent a radical prostatectomy for prostate cancer and presented with PPUI. Mean age at surgery was 66.3 (± 7.4) years and 84% were Caucasian. Median time to follow-up was 5 months (IQR 1-15). A linear regression model shows an inverse prediction curve for sling failure versus VLPP (p = 0.02). The hazard ratio for failure with a VLPP of ≤ 70 cm H2O compared with a VLPP of > 70 cm H2O, adjusted for pelvic radiation and 24-h pad weight was 0.5 (95% CI 0.2-0.98). CONCLUSION: Patient selection is imperative in the success of the male TOS for patients with PPUI. In our cohort of patients with PPUI, those with a pre-procedural VLPP of > 70 cm H2O were 50% less likely to fail after TOS placement versus those with a VLPP ≤ 70 cm H2O. In our practice, we use these data to support the use of VLPP cut off of 70 cm H2O as an indicator for success to help in the evaluation and counseling of patients.

The bidirectional association between depression and lower urinary tract symptoms (LUTS) in men: A systematic review and meta-analysis of observational studies.

BACKGROUND: Recent evidence from observational studies suggests a bidirectional association between lower urinary tract symptoms (LUTS) and depression in men. We sought to systematically quantify the effect of the presence of LUTS on depression symptoms, compared to those without LUTS, in adult males, and vice versa. METHODS: Electronic databases (MEDLINE, PsycINFO, SCOPUS, Embase) were examined for articles in English before March 2021. Observational studies of men aged over 18 years; reporting an association between LUTS and depression; including a validated scale for LUTS and depression symptoms were eligible for study inclusion. RESULTS: Seventeen studies out of 1787 records identified 163 466 men with reported depression symptoms by LUTS status, while 10 studies reported 72 363 men with LUTS by depression symptoms. Pooled estimates showed a strong effect of LUTS presence on depression risk (OR: 2.89, 95% CI: 2.50-3.33), with a high degree of heterogeneity among the examined studies (I2 = 83%; τ2 = 0,06; p < 0.001). Subgroup analyses demonstrated differences by study region (Q value:13.7, df:4, p = 0.003), setting (7.8(2), p = 0.020), design (7.2(1), p = 0.003), quality (6.2(1), p = 0.013), and LUTS measure (40.9(3), p < 0.001). Pooled estimates also showed a strong effect of depression presence on LUTS risk in men (OR: 3.13, 95% CI: 2.72-3.60), with only moderate heterogeneity between studies (I2 = 58%; τ2 = 0,02; p = 0.001). CONCLUSIONS: The strong relationship observed between LUTS and depression implies shared risk factors that cannot be solely attributed to the prostate. This has immediate implications for future studies and the assessment and management of patients with either condition.

The impact of the coronavirus disease 2019 pandemic on elective urological procedures in Australia.

OBJECTIVE: To investigate the changes in elective private urological procedures in Australia during the coronavirus disease 2019 pandemic. METHODS: Data were extracted from publicly available datasets from Medicare Benefits Schedule using item numbers assigned to each commonly performed urological intervention. These procedures were divided into three groups: Oncological therapeutic, diagnostic, and non-oncological therapeutic procedures. A smoothing model, based on the historic procedure numbers from 2017 to 2019, was used to forecast monthly number of procedures performed in each category between January 2020 and June 2020. These forecasted models were compared with reported figures. RESULTS: A total of 108 169 procedures were performed between January 2020 and June 2020 based on the Medicare Benefits Schedule item numbers listed. There was a significant reduction (percentage change) in total procedures performed in April 2020 (-22.6%, 95% confidence interval [CI]: -28.7% to -15.4%) and May 2020 (-33.2%, 95% CI: -37.5% to -28.3%). There was a significant reduction in oncological therapeutic, non-oncological therapeutic, and diagnostic procedures performed in April 2020 and May 2020 (p<0.05). These numbers did not include procedures performed in public sector. CONCLUSION: There was a significant reduction in total urological procedures (including diagnostic, oncological, and non-oncological) performed in months of April 2020 and May 2020 during time of federal restrictions. Both public and private healthcare sectors need to be supported in the upcoming months to prevent further delays in treatment and poorer clinical outcomes.

Tri-tubular penile fracture: A case of complete rupture of urethra and bilateral corpus cavernosa.

INTRODUCTION: Tri-tubular penile fracture is a very rare subset of penile fractures, typically due to high-energy trauma to the erect penis. CASE PRESENTATION: A 26-year-old healthy man presents with a triad of audible crack, immediate detumescence, and hematoma formation, following blunt trauma sustained during vaginal sexual intercourse. A diagnosis of penile fracture is made, with intraoperative finding of a complete traumatic transection of the urethra with total bilateral corpus cavernosa disruption. Both corpora cavernosa were repaired using 2/0 polydioxanone sutures, with the dartos fascia placed in between. The urethra was repaired with interrupted 5/0 polyglactin braided absorbable suture. At 5 weeks, patient reported normal erections and sexual activity with no physical or psychological issues. The literature on management was reviewed. CONCLUSION: Current evidence of surgical management of tri-tubular penile fractures remains predominantly expert opinion, due to difficulties of conducting prospective trials for a rare condition.

Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors.

OBJECTIVE: To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery. METHODS: An IRB-approved retrospective review of all patients undergoing surgery for UPF from 2012 to 2019 was performed. Demographic data were recorded. A single pathologist performed histopathologic examination of bone tissue in each case. Logistic regression and Fisher exact test were used to assess association of osteomyelitis with clinical factors. RESULTS: We identified 36 patients who underwent major extirpative surgery for UPF with bone pathology available for review. Bone histopathology findings confirmed presence of osteomyelitis in the majority (n = 32, 88.9%). This was characterized as chronic osteomyelitis in 15 (41.7%), acute osteomyelitis only in 1 (2.8%) and combined chronic, and acute osteomyelitis in 16 (44.4%). Osteonecrosis was seen in 11 cases (33.6%). There was no correlation between presence of osteomyelitis and age, timing from radiotherapy to diagnosis of UPF, type of radiotherapy, or history of endoscopic bladder outlet procedures. CONCLUSION: Osteomyelitis is present on histology of the pubic bone resected during surgery for UPF in the majority of cases (88.9%). Osteonecrosis is also common. These findings underscore the critical importance of pubic bone resection at time of UPF surgery to adequately treat the diseased bone.

Classification systems for anterior urethral stricture disease in men: a systematic review.

OBJECTIVE: To identify and explore the various classification systems that have been proposed for anterior urethral stricture disease (AUSD) and to identify the advantages and disadvantages of each. METHODS: A comprehensive systematic review was conducted in MEDLINE, EMBASE, SCOPUS and COCHRANE databases with a search strategy created appropriately. Titles and abstracts of search results were screened by two authors and selected for full-text review. Studies exploring urethral stricture classification, clinical scoring or staging systems used in men over the age of 18 with benign anterior urethral stricture disease were included. RESULTS: The search identified 3113 articles, of which 10 were selected for inclusion after scrutiny. Four classification systems were identified. These include ULTRA score, urethral stricture score, cystoscopy-based staging system and Gombe Urethrographic score. These were based on various modalities, including cystoscopy, retrograde urethrogram (RUG) and sonourethrogram (SUG). From the scoring systems identified, the urethral stricture scoring system has multiple external validation studies and is predictive of operative complexity, operative time, recurrence and postoperative complications. CONCLUSIONS: Several classification systems have been proposed for AUSD. Each has its advantages and disadvantages. The urethral stricture score has been externally validated and shown to been predictive of surgical outcomes and recurrence. There are no scores that incorporate patient-related outcome measures (PROMs). Many classification systems have yet to provide sufficient external validation. Further external validation studies are needed before the general adoption of a particular system.

Buccal mucosal ureteroplasty for the management of ureteric strictures: A systematic review of the literature.

OBJECTIVE: To review the published literature evaluating the efficacy and safety of buccal mucosa ureteroplasty. METHODS: A systematic literature review was carried out using a protocol devised a priori. The review was registered with the Joanna Briggs Institute. Results were scrutinized and full text of all relevant articles was obtained for review. RESULTS: A systematic search resulted in 1092 articles, with scrutiny resulting in 1079 exclusions. Two additional articles were identified from references, resulting in a total of 15 included studies containing a total of 72 buccal mucosal ureteroplasty procedures. A total of 34 cases were carried out using the open approach, and 38 were carried out using the robot assisted approach. The overall reported success rate was reported to be 66 out of 72 (91.6%), being 32 out of 34 (94.1%) and 34 out of 38 (89.5%) open and robotic cases, respectively. The complication rate was reported in 60 cases, being 15 out of 60 (25%) for all complications, with a 5% (3/60) rate for complications graded as Clavien-Dindo score ≥3. CONCLUSIONS: Buccal mucosa ureteroplasty appears to have high success rates and low rates of serious complications in both open and robot assisted approaches. However, the current available literature is limited to 72 cases, and further studies with larger patient populations and ongoing longitudinal review are warranted.

Extirpative Cultures Reveal Infectious Pubic Bone Osteomyelitis in Prostate Cancer Survivors With Urinary-Pubic Symphysis Fistulae (UPF).

OBJECTIVE: To examine the infectious features of patients with urinary pubic symphysis fistula (UPF) and their association with osteomyelitis. METHODS: We conducted a review of our quality improvement database for 36 patients with UPF undergoing bone resection and extirpative surgery from October 2012 to January 2019. An assessment of bone and urine cultures was carried out along with surgical, radiologic, and demographic data. We analyzed descriptive statistics and used Fisher Exact Tests and unpaired Welch t tests to assess for associations with positive bone cultures. RESULTS: In our cohort, 33 patients (91.7%) had positive bone cultures with the 3 most common organisms being candida (22.0%), enterococcus (18.0%), and pseudomonas (10.0%). There was a correlation between positive preoperative urine culture and positive bone culture (P <.01), with 63.0% of those with positive urine cultures growing the same organism on bone culture. CONCLUSION: In this series, 91.7% of patients undergoing extirpative surgery for UPF at our institution have positive bone cultures at time of pubic bone debridement. Additionally, we demonstrate a statistically significant correlation between positive urine cultures and positive bone cultures in these patients. This supports the need for a multidisciplinary approach including infectious disease, orthopedic surgery and reconstructive urology in order to address this complex clinical condition.

Association between perioperative intraperitoneal local anaesthetic infusion and long-term survival and cancer recurrence after colectomy: follow-up analysis of a previous randomized controlled trial.

BACKGROUND: High concentrations of local anaesthetic have an anti-proliferative effect on colonic cancer in vitro. Intraperitoneal local anaesthetic (IPLA) has shown analgesic benefit and improved recovery in the perioperative setting. The long-term effects of IPLA in colon cancer resection have not been examined. This study aims to review the survival and oncological outcomes of a previously conducted trial that compared perioperative IPLA with placebo. METHODS: Sixty patients underwent colonic resection for benign and malignant disease as part of a double-blinded, randomized, placebo-controlled study between September 2008 and November 2009. The IPLA group received instillation of intraperitoneal ropivacaine before dissection followed by a 3-day infusion. The placebo group was treated identically but with 0.9% saline solution. A follow-up analysis was conducted to evaluate overall survival, disease-free survival and recurrence specifically for patients undergoing resection for stages I-III colon cancer. Kaplan-Meier analysis was performed, and the log-rank test was used to evaluate difference in survival between groups. RESULTS: Thirty-seven of the 60 patients had stages I-III colon cancer and were included in this analysis. Nineteen patients were in the placebo group. There was no significant difference in overall survival or all-cause mortality. There was a higher incidence of cancer-specific mortality in the local anaesthetic group (P < 0.046). CONCLUSION: It does not appear that IPLA is associated with a significant survival benefit in patients with colonic malignancy undergoing colectomy. Other studies are needed to analyse the long-term outcomes.

Posterior urethral stenosis after prostate cancer treatment: contemporary options for definitive management.

Posterior urethral stenosis (PUS) is an uncommon but challenging problem following prostate cancer therapy. A review of the recent literature on the prevalence of PUS and treatment modalities used in the last decade was performed. A summative narrative of current accepted techniques in management of PUS is presented, and supplement with our own experience and algorithms.

A Critical Analysis of Bulbar Urethroplasty Stricture Recurrence: Characteristics and Management.

PURPOSE: We evaluated the management of recurrent bulbar urethral stricture disease after urethroplasty at our institution. MATERIALS AND METHODS: We performed an institution review board approved, retrospective case study of our urethroplasty database to collect stricture related and postoperative information with an emphasis on bulbar urethral stricture disease recurrence after urethroplasty between 1996 and 2012. Repair types included primary anastomotic, augmented anastomotic and onlay repair. Recurrence, which was defined as the need for intervention, was diagnosed with cystoscopy or retrograde urethrogram. RESULTS: We identified 437 men who underwent urethroplasty of bulbar urethral stricture disease as performed by 2 surgeons from January 1996 to December 2012. Of the men 395 had available followup data. Recurrence was identified in 25 men (6.3%), of whom all presented with symptoms, including a weak stream in 23, urinary tract infection in 1 and pyelonephritis in 1. Median time to recurrence was 10 months. Recurrence was initially treated endoscopically in 23 of 25 cases (92%), dilatation in 12 and visual urethrotomy in 11. In 5 patients (22%) further recurrence developed after endoscopic treatment, which was managed by repeat urethroplasty in 2, self-calibration only in 2 and visual urethrotomy with subsequent self-calibration in 1. We identified 2 distinct phenotypes of recurrent stricture, including type A-short focal recurrence, which may be salvaged with an endoscopic procedure, and type B-the long graft length type, which is less likely to be salvaged with endoscopy. CONCLUSIONS: Recurrence after urethroplasty is most likely to develop within the first 12 months. Type A short focal recurrence may be managed by a salvage endoscopic procedure, including dilation or visual urethrotomy. These data on the phenotype of recurrence may be useful for patient treatment.

Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging.

OBJECTIVE: To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown. MATERIALS AND METHODS: This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures. RESULTS: Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant. CONCLUSION: We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings.

Unmasking of Urinary-pubic Symphysis Fistula After Implantation of Artificial Urinary Sphincter in Prostate Cancer Survivors-User Beware.

OBJECTIVE: To describe the dramatic and rapid unmasking of urinary-pubic symphysis fistula (UPF) and chronic osteomyelitis after artificial urinary sphincter (AUS) implantation. This has never been reported as UPF is usually an insidious sequelae of radiotherapy or energy ablation for prostate cancer. METHODS: We prospectively identified men who underwent rapid clinical decline due to UPF soon after AUS implantation at our institution in the previous 24 months. Chart and imaging was reviewed to assess preoperative and postoperative factors. RESULTS: Three patients were identified. All men had undergone radiation therapy for prostate cancer and all had undergone prior manipulation of the posterior urethra for complications of radiotherapy. Radiation cystitis was present and all had a low cystometric bladder capacity before surgery. All patients declined rapidly after surgery. UPF was diagnosed in 2 men after activation of AUS at 6-7 weeks postoperatively and 1 patient presented before activation at 3 weeks postoperatively. UPF tract was demonstrated with magnetic resonance imaging in the acute phase in all 3 cases. Two patients have undergone cystectomy and loop diversion with resolution of symptoms and one patient is awaiting definitive surgery. CONCLUSION: Unmasking of occult UPF resulted in rapid clinical decline after AUS implantation. Increased intravesical filling pressure from increased urethral resistance likely resulted in opening of occult fistula tracts. UPF should be in the differential diagnosis if there is history of radiotherapy or urethral instrumentation. An underlying and undiagnosed UPF may lead to grave consequences after AUS implantation.

Recent advances in the understanding of male lower urinary tract symptoms (LUTS).

In this review, we have looked at three important areas in understanding male lower urinary tract symptoms. These are improvement in terminology, detrusor underactivity, and nocturia. Benign prostatic hyperplasia leading to bladder outlet obstruction has been covered in a previous review.