Perspectives in Urology: Point-Counterpoint Archives

Point-Counterpoint: Active Surveillance for Intermediate-Risk Disease – Con

Posted by Christopher J. Kane, MD, FACS | Nov 2023

Christopher J. Kane, MD, FACS, discusses active surveillance (AS) for intermediate-risk prostate cancer, sharing National Comprehensive Cancer Network (NCCN) Guidelines and defining favorable intermediate-risk disease. Dr. Kane shares the entry criteria for AS and then data from large randomized trials on treated vs. untreated patients that show more patients with intermediate-risk prostate cancer will die on AS as compared with radical prostatectomy, looking at data over a 20-year time horizon.

He then shares similar results from Prostate Intervention Versus Observation Trial (PIVOT) and ProtecT as well as data indicating that 50 percent of intermediate-risk patients on AS will end up with treatment within five years. Dr. Kane emphasizes that while the point of AS is to avoid overtreatment, for many intermediate-risk patients who begin with AS, treatment does occur but it occurs too late and they do not have the optimal outcomes that earlier treatment would allow.

Dr. Kane turns to progression and treatment rates for AS patients and points out that prostate-specific antigen (PSA) density is a key predictor of treatment. He shares his take-home points, including that favorable intermediate-risk prostate cancer patients are candidates for AS with comparable outcomes to low-risk disease on limited studies with short follow up. However, these patients are more likely to undergo treatment, even without reclassification/progression. He advises practitioners to consider other important clinical and pathologic factors such as percent pattern four, presence of cribiform patterns, and PSA density and the number of cores.

In conclusion, he asserts that in younger, favorable intermediate-risk patients, AS is not a sound management strategy in the hopes of avoiding treatment.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Active Surveillance for Intermediate-Risk Disease–Pro.”

Point-Counterpoint: Active Surveillance for Intermediate-Risk Disease – Pro

Posted by Aditya Bagrodia, MD | Nov 2023

Aditya Bagrodia, MD, FACS, asserts that active surveillance (AS) for intermediate-risk prostate cancer is a viable option, emphasizing the current epidemic of overtreatment. He shares data from The Prostate Cancer Intervention Versus Observation Trial (PIVOT) showing that after a median of 10 years, between-group differences in all-cause and prostate-cancer mortality were not significant among men who either had radical prostatectomy or AS.

Dr. Bagrodia shares data from the ProtecT trial on 10-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer, and he highlights morbidity data from prostate cancer among the subgroups and points out that over the years about 50 percent of patients on AS had treatment intervention. He draws the conclusion that in unselected patients with intermediate-risk (or worse) prostate cancer, early intervention is not associated with better outcomes. Additionally, many patients on AS may ultimately require treatment.

Dr. Bagrodia lists important aspects of selection such as tumor volume, percentage pattern four, adverse histology, genomic risk classifier, magnetic resonance imaging (MRI) findings, patient comorbidities, and patient compliance. He shares data showing that increased age, prostate-specific antigen (PSA) density, percentage pattern four, and core involvement were all reliable risk factors. Dr. Bagrodia addresses pathology and germline characteristics as important considerations for practitioners. He advises using molecular characteristics to augment National Comprehensive Cancer Network (NCCN) risk groups.

Dr. Bagrodia shares guidelines stating that with asymptomatic patients with limited life expectancy, clinicians should recommend AS and, for patients with favorable intermediate-risk prostate cancer, clinicians should discuss AS, radiation therapy, and radical prostatectomy. He concludes that AS is a guideline-directed option for patients with intermediate-risk prostate cancer. He emphasizes a personalized approach that considers patient comorbidities, disease features, and molecular features.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Active Surveillance for Intermediate-Risk Disease–Con.”

Point-Counterpoint: HoLEP vs. GreenLightTM PVP – GreenLightTM PVP

Posted by Seth K. Bechis, MD | Nov 2023

Seth K. Bechis, MD, compares GreenLightTM photosensitive vaporization of the prostate (PVP) to holmium laser enucleation of the prostate (HoLEP,) illustrating how PVP can safely and effectively treat benign prostatic hyperplasia (BPH) in small and large prostates. Dr. Bechis first establishes BPH prevalence and expenses. He then cites American Urological Association (AUA) guidelines on the surgical management of BPH, noting that PVP may be used on small and average prostates.

Dr. Bechis explains that large prostates are also good candidates for PVP, and PVP can offer an advantage for patients on anticoagulation. Dr. Bechis then emphasizes that 180-watt laser use contributes to properly, safely, and durably treating BPH and creating functional outcomes after two years, regardless of prostate size. He compares data between PVP outcomes on small and large prostates, reviewing differences in operative time, lasering time, and energy per unit volume of the prostate. He evaluates the similar data found between small and large prostates treated with PVP, including hospital stay, quality of life, and International Prostate Symptom Score (IPSS).

Dr. Bechis then explores a 2017 study that found that PVP creates durable results at four years, provided that energy density remains at 3 KJ/cc or higher. Dr. Bechis also stresses that keeping the retreatment rate low for PVP depends on using the correct energy density. He continues by noting that there are fewer complications with PVP compared to HoLEP. Dr. Bechis completes his discussion by examining PVP’s relatively simpler learning curve and proficiency maintenance while also highlighting PVP as a financially sound option in BPH treatment.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: HoLEP vs. GreenLightTM PVP – HoLEP.”

Point-Counterpoint: HoLEP vs. GreenLightTM PVP – HoLEP

Posted by Karen L. Stern, MD | Nov 2023

Karen L. Stern, MD, discusses holmium laser enucleation of the prostate’s (HoLEP’s) greater efficiency, safety, and durability compared to GreenLightTM photosensitive vaporization of the prostate (PVP). Dr. Stern references a 2020 study that found improved outcomes with HOLEP over PVP regarding operative time, tissue removal, International Prostate Symptom Score (IPSS) at one year, Qmax, post-void residual volume (PVR), and post-operative prostate-specific antigen (PSA). Dr. Stern then discusses small-volume prostates, emphasizing HoLEP’s effectiveness.

However, she acknowledges that PVP and transurethral resection of the prostate (TURP) are acceptable modalities in treating small-volume prostates, contrary to the treatment of large-volume prostates. Dr. Stern then reviews American Urological Association (AUA) guidelines. These note that HoLEP may serve to treat BPH and lower urinary tract symptoms (LUTS) regardless of prostate size. The AUA further notes that PVP may be less effective for large-volume prostates.

In a review of other factors, the AUA cites a 2020 study showing that PVP had a bladder outlet obstruction retreatment rate of about 27% compared to HoLEP at 5%. Dr. Stern also explains that the majority of HoLEP patients experience same-day catheter removal and discharge from hospital stays. She then evaluates the safety profile of HoLEP and PVP, finding a low rate of perioperative complications with HoLEP and high rates of urgency with PVP. Dr. Stern highlights the increased quality of life produced by HoLEP and its increased durability, boasting a reoperative rate of less than 1% per lifetime. Dr. Stern completes her discussion by reiterating HoLEP’s status as the gold standard in the surgical treatment of BPH.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: HoLEP vs. GreenLightTM PVP– GreenLightTM PVP.”

Testicular Cancer

Posted by Aditya Bagrodia, MD | Oct 2023

Aditya Bagrodia, MD, FACS, discusses testicular cancer in this lecture. Dr. Bagrodia explains that, though it is highly curable, testicular cancer is the most common cancer in men ages 18-45 and results in the most life years lost for non-pediatric cancers.

Dr. Bagrodia asserts that delays in diagnoses are associated with worse clinical outcomes. He says it is paramount to minimize toxicity while maintaining excellent oncological outcomes. The United States Preventive Services Task Force (USPSTF) recommends against screening for testicular cancer but if a patient has risk factors, self-exams are warranted.

Dr. Bagrodia covers signs and symptoms, the most common being abdominal, back, or flank pain and emphasizes that the scrotum should be checked in patients with an abdominal/retroperitoneal mass. He summarizes evaluation and explains that with a suspicious scrotal mass, ultrasound and serum tumor markers should be obtained (ideally getting staging scans prior to orchiectomy).

Dr. Bagrodia addresses prosthesis placement, fertility concerns, sperm banking, and anxiety and depression as topics practitioners should address with men who have a testicular cancer diagnosis. He addresses strategies to avoid a full orchiectomy before turning to post-orchiectomy procedures, emphasizing the importance of following serum tumor markers to nadir and a high-quality, contrasted CT scan.

Dr. Bagrodia explains stage one and stage two seminoma treatment principles and asserts that for patients undergoing both radiation and chemotherapy, the risk of long-term toxicity is significant. He explains efforts to minimize toxicity and summarizes the Surgery for Early Stage Metastatic Seminoma (SEMS) study. Dr. Bagrodia addresses stage two nonseminoma and emphasizes novel strategies to limit toxicity before concluding with a final emphasis on the curability of testicular cancer as well as the significant toxicities associated with its treatment. He asserts that efforts to minimize long-term side effects in early-stage disease are mandatory.