Have You Read?

By: Craig Niederberger, MD, FACS | Posted on: 01 Jun 2022

Kan KM, Tin AL, Stearns GL et al: De novo urinary storage symptoms are common after radical prostatectomy: incidence, natural history and predictors. J Urol 2022; 207: 601−608.

Special thanks to Drs. Jason Huang and Omer Acar at the University of Illinois at Chicago.

The most commonly studied urinary condition after radical prostatectomy is stress urinary incontinence, and clinicians often neglect storage symptoms while managing loss of urinary control after the cancer procedure. However, storage phase lower urinary tract symptoms (LUTS) impact quality of life even more so than stress incontinence and may complicate the postoperative course of radical prostatectomy.

Kan et al conducted a large retrospective review of patients who underwent radical prostatectomy at their institution to better characterize de novo urinary storage symptoms. They included more than 2,500 patients who were dry before the surgery and did not have anastomotic stricture. Storage phase LUTS were defined as symptoms of dripping or leaking urine when feeling the urge to urinate, difficulty postponing urination or needing to urinate again less than 2 hours after finishing urination in the absence of pad usage that would suggest clinically significant stress incontinence.

The authors observed that 26% of patients reported storage phase LUTS after 12 months of followup, and this incidence remained stable at 24 months. Factors associated with de novo storage phase LUTS were non-White ethnicity and a minimally invasive approach. Postoperative hematoma was another risk factor, although one with weaker statistical significance.

These findings are extremely important for preoperative counseling and postoperative care. Post-prostatectomy incontinence is not always purely stress related, and the urologist must be aware that 1 in 4 patients may instead have underlying de novo storage phase symptoms. This would warrant an alternative treatment algorithm to be instituted in a timely manner, considering the persistence rates at 24 months.

Matin SF, Pierorazio PM, Kleinmann N et al: Durability of response to primary chemoablation of low-grade upper tract urothelial carcinoma using UGN-101, a mitomycin-containing reverse thermal gel: OLYMPUS trial final report. J Urol 2022; 207: 779−788.

Special thanks to Drs. Marcin Zuberek and Simone Crivellaro at the University of Illinois at Chicago.

Low-grade urothelial carcinoma of the collecting system poses a challenge to urologists worldwide. Current recommendations involve endoscopic treatment of small size lesions, which is a challenge even in experienced hands, with recurrence rates as high as 77% within 12 months. Performing a nephroureterectomy is a decisive way to remove the entirety of the tumor but subjects the patient to life with a solitary kidney. This is where the OLYMPUS trial might offer a different treatment strategy for this challenging disease.

In their single-arm prospective trial, these investigators explored the efficacy of a mitomycin-infused gel matrix instilled in a retrograde fashion into the collecting system, where it solidifies and allows prolonged delivery of mitomycin lasting 4 to 6 hours. The results of the initial OLYMPUS trial demonstrated initial complete response in 59% of patients. The long-term followup demonstrated 82% durability response at 12 months, which is in stark contrast to the 77% recurrence rate at that time point for endoscopic treatment.

Of course, this study was not designed as a head-to-head comparison. But it does illustrate that there are options for patients with solitary kidneys, who have high failure rates on endoscopic treatment alone. It will be interesting to see the future of the gel matrix in combination with different chemotherapeutic drugs and the potential it carries. This might even become a new standard of treatment once a direct comparison to other modalities is made.

Elliott SP, Coutinho K, Robertson KJ et al: One-year results for the ROBUST III randomized controlled trial evaluating the Optilume® drug-coated balloon for anterior urethral strictures. J Urol 2022; 207: 866−875.

Special thanks to Dr. Juan Diego Cedeño at the University of Illinois at Chicago.

I felt déjà vu reading this article. In the 1970s and 1980s, surgeons performed more pectic ulcer operations than today. How do I know? Because my father was a gastrointestinal surgeon. During that time, the results of the first-generation of histamine-2 receptor antagonists were published, and the world of pectic ulcer disease shifted from surgical to medical treatment. Now, in the world of urology, a new drug-coated balloon (DCB), the Optilume®, is about to be released, a urethral dilation balloon with paclitaxel.

The ROBUST III was a randomized controlled trial evaluating the safety and efficacy of the DCB versus endoscopic treatment of recurrent anterior urethral strictures. The participants were adult males with anterior stenosis less than or equal to 12Fr and with a length less than or equal to 3 cm, at least 2 endoscopic treatments, International Prostate Symptom Score greater than or equal to 11 and peak flow rate less than 15 ml/sec. A total of 127 patients were randomized to Optilume DCB with dilation versus direct vision internal urethrotomy or dilation. At 6 months, Optilume’s success rate as defined by the ability to pass through a flexible cystoscope was 75%. Optilume DCB was also superior to direct vision internal urethrotomy or dilation in several different 1-year outcomes: 83% versus 22% without reoperation, 9 versus 20 by International Prostate Symptom Score and 16 versus 8 ml/sec peak flow rate. Most adverse events were similar except for hematuria and dysuria, which were more frequent after Optilume, at 11% and 2%, respectively.

Is this a game changer? Maybe. It’s too early to answer, and other studies need to be done to compare to the gold standard urethroplasty. It will be interesting to see how the future of this device plays out, and if direct vision internal urethrotomy becomes as much a thing of the past as did peptic ulcer surgery.