Optimizing anti-androgen treatment use among men with pathologic lymph-node positive prostate cancer treated with radical prostatectomy: the importance of postoperative PSA kinetics.

BACKGROUND: Optimal postsurgical management of prostate cancer (PCa) patients with nodal metastasis at the time of radical prostatectomy remains unclear. We sought to examine the role of postoperative PSA kinetics and pathologic tumor characteristics in guiding additional hormonal therapy use in pN1 men. METHODS: In total, 297 pN1 PCa patients treated with radical prostatectomy and ePLND between 2002 and 2018 were identified within our prospectively maintained institutional cancer data-registry. Following surgery, these patients were managed with either immediate androgen deprivation therapy (iADT) or observation with deferred ADT (dADT). The former was defined as ADT given within ≤6 months of surgery and the latter as >6 months. The primary outcome was metastasis. Regression-tree analysis was used to stratify patients into novel risk-groups based on post-prostatectomy tumor characteristics and PSA kinetics and the corresponding metastasis risk. Multivariable Cox regression analyses tested the impact of iADT versus observation ± dADT on metastasis, cancer-specific mortality, and overall mortality within each risk-group separately. RESULTS: The median follow-up was 6.1 years (IQR 3.2-9.0). Regression-tree analysis stratified patients into 3 novel risk-groups (Harrell's C-index 0.79) based on PSA-nadir and time to biochemical failure: group 1 (low-risk) included patients with time to biochemical recurrence >6 months (n = 115), while groups 2 and 3 included patients with biochemical failure within ≤6 months with a postoperative PSA-nadir <1.05 ng/mL (group 2 [intermediate-risk], n = 125) or ≥1.05 ng/mL (group 3 [high-risk], n = 57), respectively. No other patient or tumor characteristics were significant for risk stratification. Within each risk-group, the 10-year metastasis-free survival rates with iADT versus observation ± dADT use were: group 1, 100% versus 95.4% (Log-rank p = 0.738), group 2, 80.6% versus 53.5% (Log-rank p = 0.016), and group 3, 41.5% versus 0% (Log-rank p = 0.015), respectively. Adjusted Cox regression analyses confirmed the benefit of iADT utilization in reducing metastasis in group 2 (p = 0.029) and group 3 (p = 0.008) patients, with no benefit for group 1 patients (p = 0.918). Similar results were noted for cancer-specific and overall mortality. CONCLUSIONS: Following radical prostatectomy, early postoperative PSA kinetics may provide valuable information for guiding the timing of ADT initiation-this may reduce over- and undertreatment of pN1 PCa men.

Urethral duplication in an adult male: anatomic variants and operative approach to reconstruction.

Duplicated anterior urethras are a rare congenital anomaly that is exceedingly uncommon among adult patients, as surgical correction is often completed during childhood. We present the case of a 33-year-old man with uncorrected duplicated anterior urethras and urinary retention due to severe urethral stricture disease involving both of his uncorrected duplicated anterior urethras. This report highlights an operative management strategy for reconstruction to create a single, unobstructed urethra that terminates in an orthotopic meatus. Further, we provide an overview of the anatomic variants of urethral duplication.

Conservative Management of Lichen Sclerosus Male Urethral Strictures: A Multi-Institutional Experience.

OBJECTIVE: To assess the outcomes and safety of conservative management of lichen sclerosus urethral stricture disease (LS-USD). METHODS: This multi-institutional study included patients with LS-USD managed with endoscopic procedures or clean intermittent catheterization (CIC) regimens between 2005 and 2019. Those with an obliterative stricture, a history of prior urethral reconstruction, or <3 months follow-up was excluded. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, and uroflowmetry values. Secondary outcome measures included patient-reported outcome measure questionnaires on urinary and sexual function. Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. RESULTS: 112 men were analyzed with a median follow-up of 30.0 months (IQR 12.0-55.5). Median age was 52.5 years (IQR 42.6-61.0) and median body mass index was 34.5 kg/m2 (IQR 29.9-40.7). Median stricture length was 12.0 cm (IQR 2.8-20.0). 89% of patients underwent urethral balloon dilation, with a median of 2 (IQR 1-3) per patient. CIC was performed in 46% of patients, with 31% of this subgroup using intraurethral steroids. 84% of patients avoided invasive surgery or permanent indwelling catheterization, with an improvement in urethral stricture patient-reported outcome measure scores (P = .0013). Those who failed were more likely to have a history of UTI (P = .04), urosepsis (P = .03), AUR (P <.001), and more likely to perform CIC (P = .01). CONCLUSIONS: Over medium-term follow-up, most patients with LS-USD were safely managed with conservative techniques. Caution is warranted in those who develop UTIs, urosepsis, and AUR and the potential long-term consequences of repetitive conservative interventions must be considered.

The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience.

OBJECTIVE: To assess the efficacy, effect of radiotherapy, and complications of direct visual internal urethrotomy (DVIU) and intralesional mitomycin C (MMC) for recurrent bladder neck contracture/vesicourethral anastomotic stenosis (BNC/VUAS). METHODS: Patients who underwent DVIU with intralesional MMC for recurrent BNC/VUAS between 2007 and 2019 at 2 institutions were included. Cold knife incisions were performed in a reproducible fashion followed by injection of 0.3-0.4 mg/mL MMC at each incision site. Those with evidence of complete urethral obliteration, stenosis of the entire posterior urethra, or <3 months follow-up were excluded. Success was defined as the ability to pass a 17-French cystoscope postoperatively without the need for catheterization or additional procedures. RESULTS: Eighty-six patients were analyzed over a median follow-up of 21.1 months. Around 91% had at least 1 prior DVIU, 56% had at least 1 prior dilation, and 44% presented with an indwelling catheter or performed intermittent catheterization. Success was achieved in 65% after 1 procedure, an additional 18% after 2 procedures, and another 7% after 3 or more procedures (90% overall success rate). Nonradiated patients showed a higher overall success rate compared to radiated patients (94% vs 76%, P = 0.04). Of the 9 cystoscopic failures, 5 were asymptomatic and pursued observation. Only 2 (5%) patients with a history of catheterization required this postoperatively. Two patients underwent subsequent urinary diversion surgery. No long-term complications were seen. CONCLUSION: DVIU with low-dose MMC remains a safe and effective BNC/VUAS treatment. A patent bladder neck was achieved in >90% of nonradiated patients and >75% of radiated patients.