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This Month in Adult Urology

Active Surveillance vs Surgery for Prostate Cancer

Liu et al (page 1241) from Baltimore, Maryland used a Monte Carlo simulation of Markov models on the life courses of 200,000 men diagnosed with low risk prostate cancer and treated with surveillance or radical prostatectomy to calculate quality-adjusted life expectancy. They simulated outcomes for men between 50 and 75 years old with poor, average or excellent health status. Their modeling indicated that for 65-year-old men in average health, surgery resulted in 0.3 additional years of life expectancy, 1.6 additional years of impotence or incontinence, and 4.9% decrease in prostate cancer specic mortality compared to surveillance, for a net difference of 0.05 fewer quality-adjusted life years. With a greater than 95% probability, results showed that surveillance had net benets over surgery above ages 74, 67 and 54 years for men in excellent, average and poor health, respectively. The authors concluded that, in general, older men and men in poor health are likely to have better quality-adjusted life expectancy with active surveillance. sling surgery according to Brubaker et al (page 1324). Despite these low continence rates based on extremely stringent criteria, 75% of patients were satised even if they were incontinent. Satisfaction was higher in the sling group at 5 years (83% vs 73%) and remained higher although it declined with time. Repeat surgery was only necessary in 2% of the sling group vs 12% of the Burch group. Thus, the authors conclude that many women, even those who may still have incontinence, are satised with initial treatment and do not request further surgery.

Targeted Antimicrobial Prophylaxis is Associated With Reduced Post-Procedure Infections and Cost of Care
Antibiotic resistance, especially to uoroquinolones, is a growing problem resulting in infections, including sepsis, after transrectal biopsy. In an effort to reduce infection rates by using more appropriate antibiotics, Taylor et al (page 1275) from Chicago, Illinois used rectal swabs to ascertain the sensitivity patterns of fecal ora. They then looked at complications 30 days after transrectal biopsy, and noted that almost 20% of patients had uoroquinolone resistant organisms in the fecal reservoir. No infectious complications occurred in the 112 men who received targeted antibiotic prophylaxis based on swabs. However, of the 345 men who received empirical prophylaxis 9 had complications including sepsis in 1. The cost of targeted therapy vs empirical therapy for 100 men was $1,300 vs $5,600. Cost-effectiveness analysis revealed that targeted prophylaxis yielded a cost savings of $4,499 per post-transrectal ultrasound biopsy infectious complication averted. Rectal swabs would have to be used before biopsy in an estimated 38 men to prevent 1 complication. The authors did note that the mean interval between the swab and the biopsy was 20 days and may have slightly delayed some biopsies.

Long-Term Outcomes of Renal Tumor Radio Frequency Ablation Stratied by Tumor Diameter
Few studies have looked at radio frequency ablation (RFA) beyond 2 or 3 years to determine its long-term success. Best et al (page 1183) from Dallas, Texas identied 159 tumors treated with RFA, most of which were previously conrmed on biopsy to be renal cell carcinoma. Disease-free survival at 3 and 5 years was 92% and 91%, respectively, but a dependence on tumor size was noted. For tumors smaller than 3 cm, survival was 96% and 95%, respectively, and for tumors larger than 3 cm survival was 79% at both time points. Approximately 20% of tumors larger than 3 cm recurred. Although the authors warn that this series may contain some benign tumors, they conclude that smaller renal masses are more likely to benet from RFA.

Impact of Calcium Intake and Intestinal Calcium Absorption on Kidney Stones in Older Women
Growing concerns have been raised about calcium supplementation in older women with osteoporosis and whether this results in an increase in renal calculi containing calcium. The multi-institutional study by Sorensen et al (page 1287) actually demonstrated the
Vol. 187, 1145-1146, April 2012 Printed in U.S.A. DOI:10.1016/j.juro.2012.01.026

Outcomes of Burch Urethropexy and Fascial Sling Surgery for Urinary Incontinence
Continence rates 5 years after a Burch urethropexy were only 24% compared to almost 31% after fascial






opposite effect. Secondary analyses of 9,700 postmenopausal women revealed that increased dietary calcium intake reduced the likelihood of nephrolithiasis by 45% to 54%. In adjusted analyses women who took supplemental calcium were 21% to 38% less likely to have a nephrolithiasis history but there was a 24% increased risk of kidney stones for each 10% increase in fractional calcium absorption. Women with a history of renal stones were less likely to take supplemental calcium. The authors conclude that higher intestinal fractional calcium absorption is associated with a greater risk of nephrolithiasis, and dietary calcium and supplemental calcium decrease fractional calcium absorption and may protect against nephrolithiasis.

Phase 2 Study of Adjuvant Intravesical Instillations of Apaziquone for High Risk Nonmuscle Invasive Bladder Cancer
In this nonrandomized, uncontrolled, multi-institutional intention to treat study Hendricksen et al

(page 1195) investigated the use of a new bioreductive alkylating agent, apaziquone, given intravesically to 53 patients with high risk nonmuscle invasive bladder cancer. Based on recent guideline criteria, 80% and 20% of the patients were at intermediate and high risk for recurrence, and 50% and 44% were at intermediate and high risk for progression, respectively. Tumors recurred in 35% patients at 12 months and 45% at 18 months. Only 1 patient had progression to T2 disease. These results are better than expected. Bacterial and chemical cystitis was seen in 11% to 34% of cases, which is less than that reported for bacillus Calmette-Gurin or doxorubicin. Despite not being a randomized, controlled trial, these results are encouraging for a new intravesical agent with potentially fewer local side effects.
William D. Steers