Scandinavian Journal of Urology最新文献

Introduction and objectives: Definitions of prostate specific antigen progression for men with prostate cancer on androgen deprivation therapy (ADT) are mainly derived from randomised trials, and their applicability to the clinical practice remains uncertain. This study aimed to assess how different PSA-based definitions of progressions while on ADT affect estimates of progression, treatment initiation, and outcomes in men with prostate cancer.

Methods: Using data from the Prostate Cancer database of Sweden with extended treatments and endpoints data (PCBase Xtend), we identified 3718 men who initiated ADT between 2009 and 2022 and who had longitudinal PSA and treatment data. PSA progression was defined according to four modified guideline-based definitions ranging from the European Association of Urology (EAU) that has the most stringent criteria for progression to our previously used and less stringent definition (PCBase). We analysed cumulative incidence of PSA progression, treatment for castration resistant prostate cancer before and after PSA progression, and prostate cancer-specific mortality, accounting for competing risks.

Results: ADT was prescribed as the primary treatment in 52% of included men. The number of men with PSA progression ranged by definition from 1047 men (28%, EAU) to 2378 men (64%, PCBase) at 10 years after initiation of ADT. Earlier progression was observed with less stringent criteria, with a difference in median time to progression of 3 months (PCBase vs EAU). Despite variation in incidence proportion of PSA progression, the proportion of men treated within 5 years after progression was similar (45-52%), as was prostate cancer-specific mortality (26-27%) across definitions.

Conclusion: While definitions of PSA progression significantly impacted estimated incidence proportion of disease progression, they had limited influence on treatment initiation and long-term mortality. These findings suggest that in the clinical practice, decisions are guided by factors other than formal progression criteria. PSA-based definitions can be useful in observational studies if supported by sensitivity analyses.

Objective: A positive surgical margin (PSM) after radical prostatectomy (RP) is considered an adverse surgical feature, but the clinical implications have been debated. Further motive to aim for negative margins (NSM) may be patient anxiety due to PSM, but studies on psychological consequences are lacking. We explored associations between psychological factors and PSM on a consecutive group of men after RP.

Material and methods: Men with suspected prostate cancer were invited to a study on psychological factors. Patient reported outcome measurement questionnaires were collected before diagnosis, and at 6, 12 and 24 months from those who underwent RP. Multivariable mixed models and post hoc pairwise comparisons were used to explore associations between PSM and psychological outcomes.

Results: In total, 387 men had RP and 94 (24%) had PSM. General psychological outcomes were not associated with margin status. At 12 months, men with PSM considered their personal risk of recurrence 6% (30% vs. 24%) points higher and had clinical fear of recurrence (FoR) 14% (47% vs. 33%) more often than men with NSM. In adjusted and stratified analyses, men with pathological (p-)T2-stage and NSM had less FoR than the rest of the sample. In pT3-disease, PSM had no additional impact on FoR. A limitation was the small size of the pT2 group with PSM and the lack of information on how patients were informed.

Conclusions: After RP, PSM was associated with higher FoR, particularly in men with pT2-cancer. Improved counselling and further research into causes and mitigation of FoR, is warranted.

Objective: To compare lower urinary tract (LUT) symptoms in young adults with previous vesico-ureteral reflux (VUR) and healthy controls. VUR is associated with LUT dysfunction in childhood but less is known regarding long-term prognosis.

Methods: A questionnaire was sent to 483 patients treated for VUR between 1993 and 2003 and a control group of 640 healthy young adults. Presence of LUT symptoms was compared by multivariable logistic regression, expressed as odds ratios (OR) and 95% confidence intervals (CI), adjusting for age, sex and body mass index.

Results: The study group response rate was 45.8% versus 41.9% in the controls. There was a female predominance in both groups (77.9% and 74.3%). Overall, 45.7% of the VUR group and 36.6% of the controls reported current LUT symptoms, with unspecified LUT symptoms being significantly more common (OR = 3.86, 95% CI 1.33-11.20), especially in individuals receiving single treatment, and women without a pregnancy history. A larger proportion of those with VUR reported childhood incontinence than controls (20.4% vs. 5.6%, OR = 3.86, 95% CI 1.53-9.79). There were no significant differences in pyelonephritis during adulthood, yet individuals in the VUR group tended to have a higher micturition frequency than controls.

Conclusion: Bladder dysfunction related to VUR during early childhood seems to improve with age, yet voiding difficulties and a higher micturition frequency appeared to remain more common in adults, predominantly females, with previous reflux than in healthy controls.

Purpose: Lymph node dissection during radical prostatectomy (RP) remains under debate due to an unclear impact on oncological outcomes. Here, we investigate long-term oncological events after RP +/- pelvic lymph node dissection (PLND).

Methods: All patients who had an RP from 2006 to 2021 (N=15,515) in the Danish Prostate Registry were included. Cumulative incidence of biochemical failure (BF), subsequent treatment, and prostate cancer-specific death by the Aalen Johansen estimator from the time of RP were compared for men without lymph nodes removed (pNx), without positive lymph nodes (pN0), and with lymph node invasion (pN1). Area under the curve (AUC) of the receiver operating characteristic was used to determine the added value of PLND for outcome discrimination.  Results: The 15-year incidences of BF were pNx = 22% (95% confidence interval [95CI]: 20-23), pN0 = 37% (95CI: 35-39), and pN1 = 70% (95CI: 65-76). Fifteen-year incidences of subsequent treatment were 19% (95CI: 18-20), 31% (95CI: 29-33), and 84% (95CI: 79-89) for men with pNx, pN0, and pN1. Fifteen-year risk of prostate cancer-specific death was 2.1% (95CI: 1.6-2.6), 5.5% (95CI: 4.6-6.5), and 25% (95CI: 18-32) for men with pNx, pN0, and pN1. The AUC for the 10-year BF increased from 74% (95CI: 72-77) to 76% (95CI: 73-78) with the addition of pN0/pN1 in the model. The main limitation was the inability to differentiate the number of malignant nodes removed.

Conclusion: Men with positive lymph nodes after PLND faced a high risk of BF, subsequent treatment, and prostate cancer-specific death. As the addition of PLND did not substantially improve the discriminative ability, the added benefit of PLND is likely limited. The side effects of PLND should be considered in relation to its possible advantages.

Introduction: There are few studies evaluating the burden of urolithiasis on healthcare systems in Scandinavia. This study aimed to assess national trends in hospital encounters and surgical interventions for urolithiasis in Norway.

Methods: National data on hospital admissions, outpatient consultations, inpatient stays and surgical procedures were obtained from the Norwegian Directorate for Health and the Norwegian Patient Register for 2012-2023 and the operative data for 2019-2024. Variables included age and sex. Poisson regression estimated annual changes.

Results: Between 2012 and 2023, 109,490 unique patients had a hospital encounter for urolithiasis, increasing by 2.9% annually (p < 0.001). The increase was greater in males (3.2% vs. 2.6%, p < 0.001) and in those ≥70 years (6.4% vs. 2.0%, p < 0.0001). Outpatient consultations increased by 3.2% per year, with the steepest rise among older adults. Inpatient days declined annually by 2.45% (p < 0.001), while ambulatory treatments increased by 17.4% (p < 0.0001). Between 2019-2024, ureteroscopy (URS) increased from 68.6% to 80.4% of renal stone procedures and from 99% to 100% for ureteral stones. By 2024, URS accounted for 88% of all stone procedures, while shock wave lithotripsy (SWL) declined to zero for ureteral stones.

Conclusion: Urolithiasis places an increasing burden on the Norwegian healthcare system, particularly among older adults. Surgical management in Norway favours URS, representing one of the highest national proportions reported.

Standardized Care Pathway (SCP) for patients presenting with macroscopic haematuria was introduced in Sweden in 2015. In contrast to neighbouring countries, the Swedish model includes all patients with macroscopic haematuria above the age of 50, notwithstanding obvious causes. The aim of this study was to characterize the patients referred within the SCP and the presence of acute cystitis. All patients admitted to two regional hospitals in 2023, under the terms of SCP macroscopic haematuria, were included. Patient data were collected retrospectively regarding age, sex, symptoms of cystitis and cause of haematuria. The study included 782 patients. The median age was 70 years and half were women. In 89 cases, a urinary tract cancer was found (11%) and 74 (9%) had bladder cancer. The cancer-positive group was significantly older (median 75 years) and 76% were men. Half of patients (51%) had symptoms of acute cystitis on referral. This was significantly associated with the absence of bladder cancer, but only in the age groups 50-69, where no case was found among patients with symptoms of cystitis. In the age groups above, 22 cancer-positive patients (30% of all bladder cancer cases) had symptoms of cystitis. The Swedish SCP macroscopic haematuria targets younger female patients unproportionally, in comparison to where cancer is likely found. Neither symptoms of cystitis, nor positive urine cultures exclude bladder cancer in elderly, but clearly in the age groups 50-69. If excluding the latter from the SCP, a 28% reduction of examined patients can be achieved with a negligible risk of missing cancer.

Objective: Intestinal segments are commonly used in reconstructive urology to create continent or incontinent urinary channels. Initially, the viability of these segments depends on the integrity of the vascular pedicle. We report three patients with catheterizable, or incontinent channels constructed using the spiral Monti technique or incontinent ileovesicostomy all of whom developed postoperative complications involving the vascular pedicle.

Material and methods: Patients with documented vascular pedicle injury to a continent or incontinent ileovesicostomy in New Children's Hospital, Helsinki University Hospital and in Riley Children's Hospital, Indiana School of Medicine were retrospectively identified and reviewed.

Results: In all three cases, the vascular pedicle was transected either electively or during emergency surgery for intestinal volvulus or obstruction, 17 months to 5 years after reconstructive surgery. Despite pedicle loss, all patients retained viable functional channels, supported by collateral blood supply. Follow-up ranging from several months to 19 years confirmed sustained channel viability.

Conclusions: These cases suggest that, in select situations, collateral vascularization may be sufficient to preserve the function of a continent stoma despite loss of its primary vascular pedicle.

Objectives: [18F]-FDG positron emission tomography combined with computed tomography (PET/CT) allows the non-invasive assessment of inguinal lymph node (ILN) status in penile squamous cell carcinoma (PSCC). The aim of this study was to assess if the diagnostic accuracy of PET/CT was influenced by the human papillomavirus (HPV) status of the tumor.

Methods: This retrospective study included 81 treatment-naïve patients with PSCC who underwent surgery between 2010 and 2024 and had a PET/CT before ILN surgery. Inguinal results were compared with histopathology (n = 72) or follow-up findings (n = 9), stratified by HPV status.

Results: HPV DNA was detected in tumor tissue from 41 (51%) patients. The sensitivity and specificity of PET/CT to detect an ILN metastasis were 83% (69%-93%) and 68% (58%-76%), with no significant differences when stratified by HPV status (both P > 0.8). In multivariable logistic regression, after adjustment for the clinical nodal stage, the timing of PET/CT (before or after penile surgery), number of FDG-positive ILNs, the maximum standardized uptake value (SUVmax) of the ILNs and HPV status, SUVmax remained associated with ILN metastasis (OR 1.18, 95% CI: (1.05-1.38), P = 0.023). There was, however, no significant interaction between HPV status and SUVmax (P = 0.57).

Conclusions: The diagnostic accuracy of [18F]-FDG PET/CT regarding preoperative detection of ILN metastasis was not associated with the HPV status in penile cancer. These findings indicate that HPV status does not need to be considered when interpreting the inguinal findings of preoperative PET/CT scans.