Have You Read?

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

Plata Bello A, Apatov SE, Benfante NE, et al. Prevalence of high-risk prostate cancer metastasis to cloquet’s ilioinguinal lymph node. J Urol. 2022; 207(6):1222–1226.

Special thanks to Drs. Marcin Zuberek and Daniel Moreira at the University of Illinois at Chicago.

Cloquet’s node has historically been the lower limit of the external iliac lymph node dissection in prostate cancer surgery. Most urologists chased after it deep to the inguinal ligament to remove any possibility of micrometastatic disease, as it has been a part of the long standing resection template. But is such extensive dissection necessary for the benefit of the patient? Is this sentinel node of utmost importance for optimal oncologic staging and outcomes?

These authors hypothesized that it was not. In a series of 105 patients with high and very high risk prostate cancer, both nodes of Cloquet have been removed and sent for pathology separately. Forty-one percent of patients had positive lymph nodes, but only in 1% of all subjects only a single node of Cloquet was involved.

This study highlights one of the old adages in medicine: “you don’t know what you don’t know.” While the node of Cloquet has been posited to be the sentinel node for prostate cancer spread, it seems that we still have a lot to learn about this complex disease. With the new diagnostic modalities involving prostate-specific membrane antigen positron emission tomography, we may be able to better understand the progression of micrometastatic disease in prostate cancer. This can help us tailor our medical approach to a more individualized care to the point that we might diagnose and treat only the lymph nodes involved with cancer.

Anderson KT, Vanni AJ, Erickson, BA et al. Defining success after anterior urethroplasty: an argument for a universal definition and surveillance protocol. J Urol. 2022;208(1):135–143.

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

Do we need universal agreement? Many strive for that ultimate goal especially in urology practice. Urethroplasty is no exception, and the authors of this article sought to evaluate successful urethroplasty based on objective data, as there is no uniform definition of surgical success among most publications.

They compared 5 different ways to define failure in urethroplasty including stricture retreatment, anatomical recurrence as visualized by cystoscopy, a peak flow rate of less than 15 mL/second, weak stream denoted on questionnaire and failure by any of the criteria. By the Kaplan-Meier survival curves so determined, estimated probabilities of success were all over the map, ranging from 57% to 94% at 1 year and 23% to 75% at 5 years. They concluded that depending on the way success is defined, the estimated probability of success after urethroplasty changes dramatically just by changing the criteria. This is the bane that has resulted an inability to compare urethroplasty outcomes across studies.

While this result may frustrate those trying to improve urethroplasty by examining its outcomes, it reveals a fundamental truth: until we have apples to apples comparisons based on agreed on metrics, we won’t be able to know how to better our surgeries. This article serves as a call to arms to formulate those universal outcome measures.

Carnes KM, Singh Z, Ata A, Mian BM. Interventions to reduce opioid prescriptions following urological surgery: a systematic review and meta-analysis. J Urol. 2022;207(5):969–981.

Special thanks to Drs. Jason Huang and Mahmoud Mima at the University of Illinois at Chicago.

Opioid addiction is rampant in many communities throughout the United States. Sadly, up to 1 of 3 patients receiving post operative opioid pain medications may become long-term opioid users with the attendant ill health effects. How can we as urologists address this? These authors conducted a systematic review and meta-analysis to better understand how different strategies for pain control may impact patients after urological surgery.

Across 19 studies that met inclusion criteria and were sufficient for analysis, over 8,000 patients were included. Both major and minor surgeries were well represented. The authors observed that both direct interventions such as standardized prescriber pathways, provider-directed education, individual audits, patient education, and indirect interventions such as state mandated monitoring and the ERAS pathway resulted in significant reductions of prescribed opioids ranging from 6 to 10 tablets of 5 mg oxycodone. However, direct interventions, such as provider education, feedback, and individual audits appeared to have a greater impact than indirect interventions on reducing opioid prescriptions. Interestingly, these did not result in negative impacts on patient outcomes such as pain scores, phone calls or emergency room visits, additional opioid prescriptions or patient satisfaction scores.

The authors concluded that various strategies effectively reduce prescribed opioids, especially directly targeted interventions. Reductions in prescribed opioids do not lead to inferior patient outcomes or increased clinical workload. In fact, despite decreases in prescribing, patients do not use two-thirds of prescribed opioids, underscoring the need for continued reductions in opioid prescriptions.