Have You Read? November 2021
By: Craig Niederberger, MD, FACS | Posted on: 01 Nov 2021
It is with great pleasure that I take the helm of Have You Read, my favorite section in AUANews. Daniel Shoskes did an incredible job, and I know that all of us deeply thank him for his insights and views on the most pertinent urological literature of the day. For my time, in order to continue to provide the best commentary on our burgeoning specialty, I’m asking the help of my subspecialist colleagues to identify the whats and whys of the key articles in our fields. So if you want to help out, please consider emailing me at firstname.lastname@example.org. Now, let’s get to the articles for this month!
Gonzalez DC, Nassau DE, Khodamoradi K et al: Sperm parameters before and after COVID-19 mRNA vaccination. JAMA 2021; 326: 273-274.
(Special thanks to Drs. Kareim Khalafalla and Samuel Ohlander at the University of Illinois at Chicago)
As of the time of writing this in August, 2021, the COVID pandemic has taken over 4.4 million lives worldwide. We have mRNA vaccines with high efficacy and limited adverse events, but many have not been vaccinated even in areas with available supply, all while infection rates and hospitalizations climb. Those who are vaccine hesitant often cite concerns related to fertility which have been spreading on social media like wildfire. In this study, the authors conducted a prospective study to evaluate semen parameters before and after administering an mRNA vaccine in the period between December 2020 and January 2021.
A total of 45 men participated, aged 18 to 50 years. Semen samples were collected before the first dose of the mRNA vaccine and approximately 70 days after the second dose. Of the men 21 (46.7%) received Pfizer-BioNTech and 24 (53.3%) received Moderna. Spoiler alert: nothing tanked. At a median followup of 75 days after the second dose, median sperm concentration increased from 26 million/mL to 30 million/mL, median total motile sperm count increased from 36 million to 44 million, median semen volume increased from 2.2 mL to 2.7 mL, and median sperm total motility increased from 58% to 65%. Eight oligospermic men with median concentration of 8.5 million/mL were in the included cohort, 7 of whom had increased sperm concentration to normospermic counts with a median of 22 million/mL. No one became azoospermic following vaccination.
The authors concluded that the mRNA vaccine does not negatively affect semen parameters. They emphasize that as the mRNA vaccines do not contain live virus, negative impacts on semen parameters were not expected. While semen parameters do not necessarily equate to fertility, these findings support the safety of vaccines in men seeking conception, particularly given the data demonstrating substantial negative impact on semen parameters from an actual COVID-19 infection. Bottom line: assure your hesitant patients that protection from COVID with a vaccine is one of the best things they can do for their fertility.
Eklund M, Jäderling F, Discacciati A et al: MRI-targeted or standard biopsy in prostate cancer screening. N Engl J Med 2021; doi: 10.1056/NEJMoa2100852.
(Special thanks to Drs. Hari Vigneswaran and Daniel Moreira at the University of Illinois at Chicago)
Those criticizing population-based prostate specific antigen (PSA) screening for prostate cancer often cite overdiagnosis and unnecessary biopsies as its substantial pitfalls. These authors sought to tackle the limitations of population-based PSA screening by incorporating magnetic resonance imaging (MRI) in this prospective, randomized, population-based trial.
STHLM3-MRI was a trial designed to evaluate whether MRI followed by targeted and standard biopsy in PI-RADS™ (Prostate Imaging–Reporting and Data System) 3 to 5 MRI positive men was noninferior to standard biopsy for detection of clinically significant cancer defined as Gleason Grade Group 2 or higher. In this analysis the only condition for inclusion was a PSA level ≥3 ng/mL or greater to mirror the condition used in the landmark European Randomized study of Screening for Prostate Cancer.
In total, 12,750 men aged 50 to 74 years from Stockholm, Sweden underwent screening. Of these, 1,532 with PSA levels ≥3 ng/mL were randomized in a 2:3 ratio to standard biopsy or MRI using a short bi-parametric MRI protocol <16 minutes. While 36% of participants in the experimental group versus 73% in the standard biopsy group underwent biopsy, in the intention-to-treat analysis, clinically significant prostate cancer was detected in 192 of 929 (21%) participants from the experimental group and 106 of 603 (18%) in the standard biopsy group (p <0.001). Focusing on overdiagnosis, clinically insignificant cancer was diagnosed less in the experimental group than in the standard biopsy group (4% vs 12%).
The authors concluded that detection of clinically insignificant tumors and benign findings on biopsy were lower among men with positive MRI results without compromising detection of clinically significant cancers. This trial validates the utility of incorporating MRI into prostate cancer screening and draws us closer to establishing the value of screening itself for this common and too often debilitating and deadly disease.
Fedrigon D, Faris A, Kachroo N et al: SKOPE-study of ketorolac vs opioid for pain after endoscopy: a double-blinded randomized control trial in patients undergoing ureteroscopy. J Urol 2021; 206: 373-381.
(Special thanks to Drs. Susan Talamini and Daniel Moreira at the University of Illinois at Chicago)
We are deeply in the midst of an opioid epidemic, and it is in the best interests of our patients to discern exactly when and where the use of these powerful pharmacological tools best benefit them and where other agents make better sense. These investigators studied whether a nonsteroidal anti-inflammatory medication could stand in the stead of an opioid in patients undergoing ureteroscopy for urolithiasis.
The authors prescribed either 5 mg ketorolac or 10 mg oxycodone postoperatively, with 3 nonblinded oxycodone rescue pills for breakthrough discomfort, and all participants were allowed Tylenol® at home. A total of 81 patients were recruited, and the groups were similar in demographics, comorbidities, stone size or location, history of stones or stone surgery, and operative course. Patients aged 18 to 70 years with adequate renal function defined as glomerular filtration rate >60 mL/minute/1.73 m2 were enrolled. Those excluded had bleeding disorders, peptic ulcer disease, chronic kidney disease, chronic pain and opioid use, known or suspected pregnancy, and those taking anticoagulants. The primary outcome was based on the visual analogue scale measuring pain scores postoperative day 1 to 5. Secondary outcomes included: the Ureteral Stent Symptom Questionnaire; post-anesthesia care unit pain scores; use of rescue, anticholinergic, and alpha-antagonist medications; patient phone calls; emergency department and clinic visits; and hospital admissions.
These investigators observed no statistically significant differences between maximum and average pain scores across 5 postoperative days with all p values <0.001. There were also no significant differences between the opioid and nonsteroidal anti-inflammatory medication groups in percentage of patients requiring study medications (88 vs 95, p=0.439), number of rescue pills used (1.1 vs 0.8, p=0.148), or in the total number of pills consumed (7.3 vs 7.1, p=0.985). The authors concluded that nonsteroidal anti-inflammatory medications are noninferior to opioids for postoperative pain control after ureteroscopy for stone disease. We can be comfortable in prescribing these nonsteroidal anti-inflammatory medications instead of opioids in our patients undergoing ureteroscopy for urolithiasis.