Journal of Urology最新文献

Purpose: This Guideline provides a contemporary overview of vasectomy, including a discussion of indications, pre-operative counseling and preparation, peri-operative considerations, procedural techniques, potential risks and complications, and post-operative care to ensure that healthcare providers offer accurate, evidence-based information to patients considering this method of permanent contraception. Options for future fertility following vasectomy are discussed in Part II of this Guideline series.

Materials and methodology: A comprehensive search of the literature was performed and covered articles published between January 1, 1990 and January 30, 2024. Relevant study designs included randomized controlled trials, controlled clinical trials, and observational studies (cohort with and without comparison group, case-control). Systematic reviews were searched for as an additional resource to identify any relevant studies with the designs noted above that may not have been captured in the literature search.

Results: The Panel developed evidence- and consensus-based statements based on a comprehensive systematic review of the literature. Recommendations on vasectomy are detailed herein.

Conclusions: While this Guideline provides a summary of the current evidence related to vasectomy, future review will be required as knowledge in this space continues to evolve. The unabridged version of this Guideline is available at auanet.org.

Purpose: Radical cystectomy and trimodality therapy (TMT) are efficacious treatments for muscle invasive bladder cancer. Novel methods for post-treatment surveillance are needed to detect recurrence. This study assesses the value of plasma circulating tumor DNA (ctDNA) for detection of post-TMT recurrence.

Materials and methods: We performed a retrospective ctDNA analysis in 32 patients with at least one post-TMT ctDNA measurement before any disease recurrence. Patients were stratified as post-TMT ctDNA (+) or ctDNA (-) and assessed for metastasis-free survival and recurrence-free survival (RFS) using Kaplan-Meier and Cox regression methods.

Results: At a median follow-up of 181 days (range: 24-522) after the first post-TMT ctDNA measurement, 4 patients (12.5%) were ctDNA (+) and 28 patients (87.5%) were ctDNA (-); 3 of 4 ctDNA (+) patients developed radiographic evidence of metastasis. All 28 ctDNA (-) patients were without metastasis. ctDNA positivity correctly identified all metastatic progression with 100% sensitivity and 93% specificity at 6-month post-TMT ctDNA surveillance. Furthermore, ctDNA-based detection preceded clinical detection of metastasis with a median lead time of 138 days. ctDNA (+) status was associated with worse metastasis-free survival (P < .0001) and RFS (P < .0001). In univariable analysis, ctDNA (+) status was the only variable significantly associated with worse RFS (HR 3.53, 95% CI: 1.11-11.53, P = .03).

Conclusions: Plasma ctDNA is a potential biomarker for early detection of metastatic progression after TMT. Our hypothesis-generating findings provide a basis for larger studies to evaluate the utility of ctDNA-guided post-TMT surveillance.

Purpose: Guidelines usually recommend chemotherapy rather than primary retroperitoneal lymph node dissection (pRPLND) for clinical stage II nonseminomatous germ cell tumors (NSGCTs) with elevated serum tumor markers (STMs). This study evaluated oncologic and perioperative outcomes of pRPLND in patients with marker-positive vs marker-negative clinical stage II NSGCTs.

Materials and methods: A retrospective review from our prospectively maintained database identified patients undergoing pRPLND (1983-2022). The primary end point was relapse-free survival. Secondary end points included cancer-specific survival (CSS), relapse location, and perioperative outcomes. Outcomes were compared using Kaplan-Meier analysis, log-rank testing, and multivariable COX regression.

Results: Among 207 patients with NSGCTs, 65 (31%) had elevated STMs (alpha fetoprotein: 12-376 µg/L; human chorionic gonadotropin: 3-354 IU/L). Marker elevation was associated with higher relapse risk, with 5-year relapse-free survival of 75% vs 93% for marker-negative patients (P < .001). Five-year CSS was 96% vs 100% (P = .009). Of 4 cancer-specific deaths, 2 involved somatic transformation, 1 patient declined chemotherapy at relapse, and 1 death occurred during chemotherapy. Elevated alpha fetoprotein correlated with worse CSS, and dual marker elevation predicted greater relapse risk. Surgical complication rates did not differ between groups.

Conclusions: Although elevated STMs are associated with increased relapse and mortality risk, pRPLND is associated with long-term disease control in approximately 75% of patients. Most relapses can be successfully treated in compliant individuals. Multidisciplinary decision-making should weigh relapse risk and potential salvage chemotherapy needs against the long-term morbidity of primary chemotherapy.