Publications by authors named "Kevin C Zorn"

257 Publications

Editorial Comment.

J Urol 2021 Feb 24:101097JU000000000000156102. Epub 2021 Feb 24.

Division of Urology, University Health Network, University of Toronto, Ontario, Canada.

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http://dx.doi.org/10.1097/JU.0000000000001561.02DOI Listing
February 2021

Letter to the Editor.

Can J Urol 2021 Feb;28(1):10506-10507

Faculty of Medicine, McGill University, Montreal, Quebec, Canada.

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February 2021

Which Anatomic Structures Should Be Preserved During Aquablation Contour Planning to Optimize Ejaculatory Function? A Case-control Study Using Ultrasound Video Recordings to Identify Surgical Predictors of Postoperative Anejaculation.

Urology 2021 Jan 20. Epub 2021 Jan 20.

Division of Urology, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada. Electronic address:

Objective: To identify key anatomic structures that should be preserved to decrease postoperative anejaculation after Aquablation.

Methods: We conducted a case-control study design using patient data and operative video logs from Aquablation clinical trials. Cases were sexually active participants with functional baseline ejaculation and postoperative anejaculation. Controls were sexually active participants with functional baseline ejaculation and no postoperative decline in sexual function. Each case was matched to 1 or 2 controls. Video logs from the procedure were scored for: verumontanum cut coverage, penetration of ejaculatory ducts, depth of cut below the verumontanum, angle offset of verumontanum to centerline of protection zone, number of passes, and intraprostatic calcifications. Conditional logistic regression was used to calculate univariate odds ratios relating anatomic findings to case/control status.

Results: We identified 24 cases and 27 controls. In univariate analysis, predictors of postoperative anejaculation were: penetration of the ejaculatory ducts (odds ratio [OR] 8.6 [95% CI 1.09-67.5], P = .041) and depth below the verumontanum (OR 1.92 [1.1-3.3], P = .015).

Conclusion: Violation of anatomic structures involved in ejaculation during the Aquablation procedure increases the risk of postoperative anejaculation. More careful attention to these structures during contour planning may further improve ejaculatory function after Aquablation.
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http://dx.doi.org/10.1016/j.urology.2021.01.023DOI Listing
January 2021

Impact of the presence of a median lobe on functional outcomes of greenlight photovaporization of the prostate (PVP): an analysis of the Global Greenlight Group (GGG) Database.

World J Urol 2021 Jan 3. Epub 2021 Jan 3.

Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.

Objectives: Previous analyses of the impact of median lobe presence on Greenlight photoselective vaporization of the prostate (PVP) outcomes were limited by their small sample size and the ability to adjust for important confounders. As such, we sought to investigate the impact of prostate median lobe presence on the operative outcomes of 180 W XPS GreenLight PVP using a large international database.

Methods: Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. All men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible for the study. Patients were assigned to two groups based on presence or absence of median lobes. Analyses were adjusted for patient age, prostate volume, body mass index, and American Society of Anesthesia (ASA) score.

Results: A total of 1650 men met the inclusion criteria. A median lobe was identified in 621 (37.6%) patients. Baseline prostate volume, patient age, and ASA score varied considerably between the two groups. In adjusted analyses, the operative and lasing time of patients with median lobes was 6.72 (95% CI 3.22-10.23; p < 0.01) minutes and 2.90 (95% CI 1.02-4.78; p < 0.01) minutes longer than the control group. Men with median lobes had similar postoperative functional outcomes to those without a median lobe except for a 1.59-point greater drop in the 12-month IPSS score compared to baseline (95% CI 0.11-3.08; p = 0.04) in the median lobe group, and a decrease in PVR after 6 months which was 46.51 ml (95% CI 4.65-88.36; p = 0.03) greater in patients with median lobes compared to men without median lobes.

Conclusions: Our findings suggest that the presence of a median lobe has no clinically significant impact on procedural or postoperative outcomes for patients undergoing Greenlight PVP using the XPS-180 W system.
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http://dx.doi.org/10.1007/s00345-020-03529-wDOI Listing
January 2021

Development of a patient decision aid for the surgical management of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

BJU Int 2021 Jan;127(1):131-135

Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada.

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http://dx.doi.org/10.1111/bju.15307DOI Listing
January 2021

Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials.

Sex Med Rev 2021 Jan 9;9(1):169-173. Epub 2020 Dec 9.

Division of Urology, University Health Network (UHN), University of Toronto, Toronto, ON, Canada.

Introduction: Traditional benign prostatic hyperplasia treatment options, such as transurethral resection of the prostate and laser, have focused on addressing urinary symptoms for men; however, these options are associated with a high risk of sexual dysfunction.

Objective: The objective of this study was to assess newer technologies (Aquablation therapy, UroLift, and Rezum) for the treatment of benign prostatic hyperplasia and the impact of preserving sexual function compared with transurethral resection of the prostate.

Methods: A comprehensive review of Food and Drug Administration randomized studies from each of the technologies was carried out. A comparison of 3-year outcomes for International Index of Erectile Function-5 and Male Sexual Health Questionnaire Ejaculatory Function domain short form was analyzed.

Results: Aquablation and prostatic urethral lift were the only therapies to show permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment.

Conclusion: For prostates less than 80 cc, Aquablation and prostatic urethral lift were able to demonstrate permanent sexual function preservation in both Male Sexual Health Questionnaire Ejaculatory Function domain short form (ejaculatory function) and International Index of Erectile Function-5 (erectile function) at 3 years after treatment. Bhojani N, Yafi FA, Misrai V, et al. Review of Sexual Preservation After Novel Benign Prostatic Hyperplasia Surgical Treatment Modalities From Food and Drug Administration Clinical Trials. Sex Med Rev 2021;9:169-173.
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http://dx.doi.org/10.1016/j.sxmr.2020.09.003DOI Listing
January 2021

A shared decision: Bipolar vs. monopolar transurethral resection of the prostate for benign prostatic hyperplasia.

Can Urol Assoc J 2020 Dec;14(12):431

Division of Urology, University Health Network, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.5489/cuaj.6563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704093PMC
December 2020

External beam radiation therapy improves survival in elderly metastatic prostate cancer patients with low PSA.

Urol Oncol 2021 Feb 11;39(2):131.e1-131.e7. Epub 2020 Nov 11.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: It is unknown, whether metastatic prostate cancer (CaP) patients with intermediate life expectancy (5-10 years) should be considered for external beam radiation therapy (EBRT) to the prostate. We addressed this void.

Methods: Within the Surveillance, Epidemiology, and End Results database (2004-2016), we identified 835 M1a or M1b CaP substaged patients with prostate-specific antigen (PSA) < 20 ng/ml and with intermediate life expectancy (LE) 5 to 10 years, treated with EBRT or no EBRT. Inverse probability of treatment-weighting (IPTW), Kaplan-Meier plots and Cox-regression models (CRMs) were used.

Results: Overall, 179 (21.4%) patients received EBRT and 656 (78.6%) did not. EBRT rates increased from 13.9 to 23.8% (2004-2016; P= 0.04). After IPTW-adjustment, median OS was 45 vs. 35 months, in EBRT vs. no EBRT patients (P < 0.001). In IPTW-adjusted Cox-regression models, EBRT independently predicted lower overall mortality (hazard ratio [HR]: 0.7, CI 0.61-0.89; P= 0.001). After stratification according to M1 substages, EBRT was associated with lower overall mortality in M1a (HR: 0.2, CI 0.05-0.91; P= 0.03) and M1b (HR: 0.7, CI 0.55-0.88; P = 0.003) substages.

Conclusion: EBRT was associated with lower mortality in metastatic CaP patients with low PSA and intermediate LE (5-10 years). In consequence, greater consideration for EBRT should be given in those patients. However, it is important to consider study limitations until clinical trials confirm the proposed benefit.
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http://dx.doi.org/10.1016/j.urolonc.2020.10.011DOI Listing
February 2021

Prostate Cancer Grade and Stage Misclassification in Active Surveillance Candidates: Black Versus White Patients.

J Natl Compr Canc Netw 2020 11 2;18(11):1492-1499. Epub 2020 Nov 2.

1Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Background: Misclassification rates defined as upgrading, upstaging, and upgrading and/or upstaging have not been tested in contemporary Black patients relative to White patients who fulfilled criteria for very-low-risk, low-risk, or favorable intermediate-risk prostate cancer. This study aimed to address this void.

Methods: Within the SEER database (2010-2015), we focused on patients with very low, low, and favorable intermediate risk for prostate cancer who underwent radical prostatectomy and had available stage and grade information. Descriptive analyses, temporal trend analyses, and multivariate logistic regression analyses were used.

Results: Overall, 4,704 patients with very low risk (701 Black vs 4,003 White), 17,785 with low risk (2,696 Black vs 15,089 White), and 11,040 with favorable intermediate risk (1,693 Black vs 9,347 White) were identified. Rates of upgrading and/or upstaging in Black versus White patients were respectively 42.1% versus 37.7% (absolute Δ = +4.4%; P<.001) in those with very low risk, 48.6% versus 46.0% (absolute Δ = +2.6%; P<.001) in those with low risk, and 33.8% versus 35.3% (absolute Δ = -1.5%; P=.05) in those with favorable intermediate risk.

Conclusions: Rates of misclassification were particularly elevated in patients with very low risk and low risk, regardless of race, and ranged from 33.8% to 48.6%. Recalibration of very-low-, low-, and, to a lesser extent, favorable intermediate-risk active surveillance criteria may be required. Finally, our data indicate that Black patients may be given the same consideration as White patients when active surveillance is an option. However, further validations should ideally follow.
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http://dx.doi.org/10.6004/jnccn.2020.7580DOI Listing
November 2020

Impact of surgical wait times during summer months on the oncological outcomes following robotic-assisted radical prostatectomy: 10 years' experience from a large Canadian academic center.

World J Urol 2020 Oct 27. Epub 2020 Oct 27.

Department of Surgery, Division of Urology, Centre Hospitalier de L'université de Montréal (CHUM), Montreal, QC, Canada.

Purpose: Most Canadian hospitals face significant reductions in operating room access during the summer. We sought to assess the impact of longer wait times on the oncological outcomes of localized prostate cancer patients following robotic-assisted radical prostatectomy (RARP).

Methods: We conducted a retrospective review of a prospectively maintained RARP database in two high-volume academic centers, between 2010 and 2019. Assessed outcomes included the difference between post-biopsy UCSF-CAPRA and post-surgical CAPRA-S scores, Gleason score upgrade and biochemical recurrence rates (BCR). Multivariable regression analyses (MVA) were used to evaluate the effect of wait times.

Results: A total of 1057 men were included for analysis. Consistent over a 10 year period, summer months had the lowest surgical volumes despite above average booking volumes. The lowest surgical volume occurred during the month of July (7.1 cases on average), which was 35% less than the cohort average. The longest average wait times occurred for patients booked in June (93 ± 69 days, p < 0.001). On MVA, patients booked in June had significantly more chance of having an increase in CAPRA score [HR (95% CI) 1.64 (1.02-2.63); p = 0.04] and in CAPRA risk group [HR (95% CI) 1.82 (1.04-3.19); p = 0.03]. Cohort analysis showed fair correlation between CAPRA-score difference and wait time (Pearson correlation: r =  - 0.062; p = 0.044).

Conclusion: Our cohort results demonstrate that conventional RARP wait times are significantly and consistently prolonged during summer months over the past 10 years, with worse post-RARP oncological outcomes in terms of CAPRA scores. Other compensatory mechanisms to sustain consistent yearly operative output should be considered.
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http://dx.doi.org/10.1007/s00345-020-03496-2DOI Listing
October 2020

Oncological safety and functional outcomes of testosterone replacement therapy in symptomatic adult-onset hypogonadal prostate cancer patients following robot-assisted radical prostatectomy.

World J Urol 2020 Oct 9. Epub 2020 Oct 9.

Département d'Urologie, Robotic Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.

Purpose: Testosterone replacement therapy (TRT) remains controversial in men with treated prostate cancer. We assessed its safety and functional impacts in patients after definitive surgical treatment with robotic-assisted radical prostatectomy (RARP).

Methods: We performed a retrospective analysis of 1303 patients who underwent RARP during the years 2006-2019. We identified men with symptoms of andropause and low serum testosterone who received TRT post-RARP; then we divided the cohort into two groups accordingly for comparison. Biochemical recurrence (BCR) was the primary endpoint. Secondary endpoints included functional outcomes. Predictors of BCR, including the effect of TRT on BCR, were evaluated using univariable and multivariable logistic regression.

Results: Among the forty-seven men who received TRT, the mean age was 60.83 years with a median follow-up of 48 months. Three (6.4%) and 157 (12.56%) patients experienced BCR in TRT and non-TRT groups, respectively. Baseline characteristics were similar between both groups except for higher mean BMI in the TRT group (p = 0.03). In the multivariate analysis (MVA), higher pre-RARP prostate-specific antigen (PSA) (p = 0.043), higher International Society of Urological Pathology score (p < 0.001), seminal vesical invasion (p = 0.018) and positive surgical margin (p < 0.001) were predictors of BCR. However, TRT was not (p = 0.389). In addition, there was a significant change in the Sexual Health Inventory for Men (p = 0.022), and serum testosterone level (p < 0.001) before and 6 months after initiation of TRT.

Conclusion: Our findings suggest that TRT, in well-selected, closely followed, symptomatic men post-RARP is an oncologically safe and functionally effective treatment in prostate cancer patients post-RARP.
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http://dx.doi.org/10.1007/s00345-020-03475-7DOI Listing
October 2020

Reasons to go for Rezūm steam therapy: an effective and durable outpatient minimally invasive procedure.

World J Urol 2020 Sep 23. Epub 2020 Sep 23.

Division of Urology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.

Purpose: In this review, we will discuss the state of the literature regarding Rezūm and opportunities for its application in the treatment of BPH.

Methods: A comprehensive review of original research on convective water vapor thermal therapy (Rezūm) was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, Aquablation, and greenlight photoselective vaporization of the prostate were reviewed for discussion.

Results: Rezūm distinguishes itself from other treatment options by its durable improvement in objective clinical outcomes such as IPSS and BPH Impact Index, while being cost-effective and versatile in its ability to treat a variety of prostate gland morphologies. This treatment option shows good lower urinary tract symptom relief, especially in small-to-moderate prostate sizes (30-80 cc). The use of convective heat transfer is unique and allows for localized treatment, avoiding damage to surrounding structures, thus providing an excellent safety profile and sexual function preservation.

Conclusion: The current evidence on Rezūm warrants its consideration as a therapeutic alternative to transurethral surgery in selected patients.
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http://dx.doi.org/10.1007/s00345-020-03457-9DOI Listing
September 2020

Relief of Lower Urinary Tract Symptoms After MRI-Guided Transurethral Ultrasound Ablation for Localized Prostate Cancer: Subgroup Analyses in Patients with Concurrent Cancer and Benign Prostatic Hyperplasia.

J Endourol 2021 Jan 21. Epub 2021 Jan 21.

London Health Sciences Center, Western University, London, Canada.

MRI-guided transurethral ultrasound ablation (TULSA) offers minimally invasive thermal ablation of benign and malignant prostate tissue, using directional high-intensity ultrasound and real-time, magnetic resonance thermometry feedback control. Feasibility of TULSA for alleviating lower urinary tract symptoms (LUTSs) associated with benign prostatic hyperplasia (BPH) is retrospectively assessed in a subgroup of men from a localized prostate cancer study who also had LUTSs. TULSA was used to ablate 90% of the prostate gland in 30 men with localized prostate cancer, without plans to spare ejaculatory ducts. Mean ± standard deviation treatment time was 37 ± 10 minutes. Retrospective analysis was conducted on a subpopulation of nine patients who also suffered from LUTSs (International Prostate Symptom Score [IPSS] ≥ 12 at baseline) as well as a smaller subgroup of five patients with IPSS >12 and peak urinary flow (Q) <15 mL/second. Urinary symptom relief, continence, and erectile function were assessed using IPSS, International Index of Erectile Function (IIEF), and uroflowmetry. At 12 months post-TULSA, IPSS improved significantly by 58% to 6.3 ± 5.0 ( = 0.003), with at least a moderate (≥6 points) reduction in eight of nine patients. IPSS quality of life improved in eight of nine patients. Erectile function (IIEF-EF) remained stable from 14.6 ± 9.3 at baseline to 15.7 ± 9.0 at 12 months. The proportion of patients with erections sufficient for penetration (IIEF Q2 ≥2) was unchanged. Full urinary continence (pad free and leak free) was achieved at 12 months in all patients. In five men who suffered from more severe symptoms, Q increased from 11.6 ± 2.6 mL/second to 22.5 ± 14.2 mL/second at 12 months ( = 0.126). Perfused prostate volume, measured on MRI, decreased 70% to 13.6 ± 4.6 mL ( = 0.003) at 12 months. All adverse events were mild to moderate (Common Terminology Criteria for Adverse Events [CTCAE] Grade 1-2) with no serious events reported. This retrospective analysis demonstrates promising safety and feasibility of TULSA to relieve LUTSs, with improvement in IPSS comparable with modern, minimally invasive surgical therapies. Larger controlled studies with BPH-specific ablation plans in men seeking treatment for LUTSs are warranted.
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http://dx.doi.org/10.1089/end.2020.0511DOI Listing
January 2021

Reasons to believe in vaporization: a review of the benefits of photo-selective and transurethral vaporization.

World J Urol 2020 Sep 15. Epub 2020 Sep 15.

Département d'Urologie, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.

Purpose: In the current review, we will discuss the state of the literature of vaporization of the prostate for the treatment of benign prostatic enlargement (BPE). We discuss two methods of vaporization of the prostate: Transurethral Vaporization of the Prostate (TUVP) and Greenlight Photo-selective Vaporization of the Prostate (PVP).

Methods: A comprehensive review of the literature was performed on TUVP and PVP. The literature on transurethral resection of the prostate (TURP) was also extensively reviewed as a comparative surgical method.

Results: The evidence shows that TUVP appears to be the safer choice, as compared to TURP due to less intra- and peri-operative complications. PVP was associated with less bleeding complications than TURP with outpatient discharge. Importantly, PVP was not associated with serious bleeding events requiring blood transfusions or medical treatment in patients under anticoagulation or antiplatelet therapies. PVP was also shown to be a cost-effective option compared to TURP.

Conclusion: Prostate vaporization for the treatment of BPE appears to be an efficient and safer alternative to TURP. Vaporization techniques, particularly Greenlight PVP, should be offered to most men, especially those under anticoagulation therapy, as well as patients at risk of bleeding complications.
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http://dx.doi.org/10.1007/s00345-020-03447-xDOI Listing
September 2020

Patient Perspectives on Benign Prostatic Hyperplasia Surgery: A Focus on Sexual Health.

J Sex Med 2020 10 6;17(10):2108-2112. Epub 2020 Aug 6.

Division of Urology, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada. Electronic address:

Background: In the last decade, many novel minimally invasive surgical techniques within benign prostatic hyperplasia (BPH) surgery were developed to reduce postoperative complications that often discourage patients from pursuing BPH surgery.

Aim: To assess perspective of future and past international BPH surgery patients regarding their postoperative complications, namely erectile and ejaculatory function.

Methods: A survey was distributed randomly to 2 groups of BPH patients: one with 149 patients having undergone surgery in the last 2 years (group A), and the other cohort of 151 men seriously considering BPH surgery in the next year (group B). This survey consisted of 20 questions that assessed patients' motivating factors for undergoing elective BPH surgery and their perspectives regarding the potential postoperative complications attributed to BPH surgery.

Outcomes: The perspective of future and past international BPH surgical patients towards the preservation of their erectile and ejaculatory functions was assessed with the help of a survey.

Results: Results indicated that in general BPH surgery patients considered the maintenance of erectile (95%, n = 284) and ejaculatory function (92%, n = 276) to be important preoperative considerations, regardless of their age. Patients aged 50-59 years were most concerned with the permanent impact on sexual function and patients aged >60 years were most concerned with urinary incontinence. In patients aged >70 years, 66% (n = 43) and 62% (n = 40) of the respondents indicated that maintaining erectile and ejaculatory function was important, respectively.

Clinical Implications: Patient-centered care needs to be implemented in order to address the importance that past and future BPH surgery patients hold toward the maintenance of their postoperative sexual function.

Strengths & Limitations: In the group of patients having previously undergone BPH surgery, the possibility of recall bias should be taken into account when interpreting the study's findings. However, maintaining sexual function was also important for the group of patients seriously considering surgery in the next year suggesting that these considerations are not solely due to recall bias. Additionally, the results were limited by the small sample size of participants in groups A (n = 149) and B (n = 151).

Conclusion: It was found that past and future BPH surgery patients attribute a significant importance toward the maintenance of their sexual function. Although novel approaches with better sexual outcomes such as Rezum and UroLift for prostates <80 mL, and Aquablation for any size prostate are available, more research is needed to investigate their long-term effects on sexual function before they can be recommended to patients. Bouhadana D, Nguyen D-D, Zorn KC, et al. Patient Perspectives on Benign Prostatic Hyperplasia Surgery: A Focus on Sexual Health. J Sex Med 2020;17:2108-2112.
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http://dx.doi.org/10.1016/j.jsxm.2020.07.006DOI Listing
October 2020

Reasons to overthrow TURP: bring on Aquablation.

World J Urol 2020 Aug 1. Epub 2020 Aug 1.

Division of Urology, Centre Hospitalier de L'Université de Montréal, Montreal, QC, Canada.

Purpose: In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE).

Methods: A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion.

Results: For small-medium prostates (30-80 mL), Aquablation's main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80-150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern.

Conclusion: The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.
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http://dx.doi.org/10.1007/s00345-020-03390-xDOI Listing
August 2020

Detectable Prostate-specific antigen value between 0.01 and 0.1 ng/ml following robotic-assisted radical prostatectomy (RARP): does it correlate with future biochemical recurrence?

World J Urol 2020 Jul 21. Epub 2020 Jul 21.

Division of Urology, Department of Surgery, Centre Hospitalier de l'université de Montréal (CHUM), 1000 Rue Saint-Denis, Montreal, QC, Canada.

Purpose: The aim of the study is to evaluate the impact of having a nadir and persistently detectable ultrasensitive prostate-specific antigen (uPSA) between 0.01 and 0.1 ng/ml post-robot-assisted radical prostatectomy (RARP), on future biochemical recurrence (BCR).

Methods: We conducted a retrospective analysis of a prospectively maintained cohort of 1359 men who underwent RARP, between 2006 and 2019. Patients were followed with uPSA at 1, 3, 6, 9, 12, 18, 24, 30, 36 months and annually thereafter. We included patients with PSA nadir values between 0.01 and 0.1 ng/ml within 6 months of surgery and with at least 2 follow-up measurements within the same range. We divided patients based on their BCR status and analyzed uPSA changes. Multivariable Cox-regression models (CRMs) were used to analyze variables predicting BCR-free survival (BCR-FS).

Results: We identified 167 (12.3%) patients for analyses, with a mean follow-up time of 60.2 ± 31.4 months. In our cohort, 5-year BCR-FS rate was 86%. Overall, 32 (19.1%) patients had BCR, with a mean time to BCR of 43.7 ± 24.3 months. BCR-free patients had stable mean uPSA values ≤ 0.033 ng/ml, while patients who developed BCR showed a slowly rising trend over time, with a significant difference between groups starting at 9 months (p < 0.02). In multivariable CRMs, a rising uPSA starting at 9 months was an independent predictor of BCR (HR: 2.7; 95% CI 1.6-3.82; p = 0.013).

Conclusion: In the present cohort, our results demonstrated that a considerable number of men have detectable uPSA values ranging between 0.01 and 0.1 ng/ml post-RARP. They can still be followed regularly to avoid patients' anxiety and salvage radiotherapy. Close follow-up is still required.
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http://dx.doi.org/10.1007/s00345-020-03367-wDOI Listing
July 2020

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

Can Urol Assoc J 2020 Sep;14(9):E387-E393

Center for Outcomes Research, Houston Methodist Hospital, Medical Center, Houston, TX, United States.

Introduction: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes.

Methods: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting.

Results: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles).

Conclusions: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.
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http://dx.doi.org/10.5489/cuaj.6579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492033PMC
September 2020

Do Women Have Equal Chances for an Academic Career in Radiation Oncology in Canada? A Comparison With Related Specialties.

Adv Radiat Oncol 2020 May-Jun;5(3):313-317. Epub 2019 Oct 16.

Department of Radiation Oncology Centre, Hospitalier de l'Université de Montréal (CHUM), Montreal, Canada.

Purpose: The progress of women in academic medicine appears to be curtailed. We evaluated gender differences in academia for residents in radiation oncology compared with 2 of its related specialties, radiology and medical oncology, across Canada.

Methods And Materials: We analyzed abstracts presented between 2013 and 2016 at the annual meetings of the Canadian Association of Radiation Oncologists and compared it to the corresponding data for the meetings of the Canadian Association of Radiologists and Canadian Association of Medical Oncology. We further evaluated gender composition of abstracts, presentations, and publications available on PubMed. Conversion rates according to gender and to medical specialties were assessed. Proportions were compared using Fisher exact test or the chi-squared test.

Results: Among the 198 presented abstracts, 103 (52%) were published. Radiation oncology had the highest publishing rate with 90% (oncology 56%, radiology 40%). The publication rate between the medical specialties was significantly different ( < .001).Fifty-seven percent of abstracts presented by women were published versus 48% of abstracts presented by men. Overall, there was no significant difference between genders in terms of subsequent conversions into a scientific publication within each specialty ( = .25-1.0).In radiation oncology, women presented 67% of abstracts and published 95% of their presented abstracts, and in medical oncology, 66% of abstracts were from women and 57% of the presented abstracts were published. Among the published abstracts, 83% had the same first author in the abstract and the publication. Among those who lost their first-authorship status, 59% were women. However, there was no statistically significant difference between specialties for loss of first-author status.

Conclusions: We observed that from 2013 to 2016, women had the highest presentation and publication rate in radiation oncology. More prospective data are needed to monitor the progress of women in all specialties and their specific needs.
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http://dx.doi.org/10.1016/j.adro.2019.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276660PMC
October 2019

Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 2-year results.

Can J Urol 2020 04;27(2):10147-10153

University of Southern California, Institute of Urology, Los Angeles, California, USA.

Introduction: To report 2-year safety and effectiveness of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH) and large-volume 80-150 cc prostates.

Materials And Methods: Between September-December 2017, 101 men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cc underwent an ultrasound-guided robotically executed Aquablation procedure in a prospective multicenter international clinical trial (WATER II). Baseline, procedural and follow up parameters were recorded at baseline and scheduled postoperative visits. Herein we report 2-year safety and efficacy for this cohort.

Results: Mean prostate volume was 107 cc (range 80-150 cc). Mean IPSS improved from 23.2 at baseline to 5.8 at 2 years (17-point improvement, p < .0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 2 years (p < .0001). Maximum urinary flow increased from 8.7 to 18.2 cc/sec. Two subjects underwent a repeat procedure for BPH symptoms over the 2-year follow up period. By 2 years or study exit, all but 2 of 74 subjects stopped taking alpha blockers. Similarly, all but 4 of 32 subjects stopped taking 5α-reductase inhibitors.

Conclusions: Two-year prospective multicenter follow up demonstrated that the Aquablation procedure is safe and effective in the treatment of men with LUTS due to BPH and prostates 80-150 cc with durable treatment efficacy, acceptable safety profile and a low retreatment rate. ClinicalTrials.gov number, NCT03123250.
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April 2020

A Plea for the Evaluation of the Carbon Footprint of New Mini-invasive Surgical Technologies in Urology.

Eur Urol 2020 09 21;78(3):474-476. Epub 2020 Mar 21.

Sorbonne Université, GRC n°5, Oncotype-Uro, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France.

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http://dx.doi.org/10.1016/j.eururo.2020.03.006DOI Listing
September 2020

Operative time comparison of aquablation, greenlight PVP, ThuLEP, GreenLEP, and HoLEP.

World J Urol 2020 Dec 2;38(12):3227-3233. Epub 2020 Mar 2.

Division of Urology, University of Montreal Hospital Center, Université de Montréal, Montreal, Canada.

Introduction: The BPH surgical armamentarium is composed of a rapidly expanding number of technologies and techniques. These include greenlight photovaporization of the prostate (PVP), greenlight enucleation of the prostate (GreenLEP), holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP) and, more recently, the aquablation procedure. To the best of our knowledge, no direct comparison in operative time has been performed.

Methods: Data for this study were pooled from five sources. For aquablation, patient-level data from four studies of the aquablation procedure were provided by the device manufacturer as well as from a high-volume commercial user. PVP, GreenLEP, HoLEP, and ThuLEP were performed by high-volume, experienced experts. Endpoints included total operative time, resection time, and proportion of total operative time for resection. General linear models were used to evaluate the relationship between prostate volume (or other continuous predictors) and procedure time.

Results: Total procedure time was related to prostate size. Except for the small prostate size range (size < 40 cc), at any given prostate volume, procedure time was highest for PVP, intermediate for LEPs, and lowest for Aquablation. The relationship between procedure time and prostate size (i.e., slope of the fitted lines) was 0.16 min/g for aquablation, 0.32 min/g, 0.28 min/g and 0.32 min/g for GreenLEP, HoLEP and ThuLEP, respectively, and 0.63 min/g for PVP.

Conclusion: In our analysis of pooled data of multi-surgical techniques and technologies, aquablation provided the lowest operative time across all prostate volumes. PVP had the longest procedure time for prostates > 40 cc.
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http://dx.doi.org/10.1007/s00345-020-03137-8DOI Listing
December 2020

Diagnosis of prostate cancer: the implications and proper utilization of PSA and its variants; indications and use of MRI and biomarkers.

Can J Urol 2020 02;27(27 Suppl 1):3-10

Faculty of Medicine, McGill University, Montreal, Quebec, Canada.

Prostate cancer screening remains highly controversial in medicine. The College of Family Physicians of Canada currently endorses positions that recommend against prostate-specific antigen (PSA) screening in men of all ages, while the Canadian Urological Association recommends shared and informed decision making for PSA screening in men 50-70 years old. Unfortunately, these opposing stances have left Family Physicians responsible for interpreting the appropriate course of action for their patients. Recent studies demonstrating an increase in incidence of metastatic prostate cancer have led to our support of the Canadian Urological Association recommendations. In an attempt to facilitate initial patient investigation, this article aims to outline current prostate cancer screening recommendations, as well as the various screening modalities available. The utility of PSA-based tests, serum and non-serum biomarkers, and multiparametric magnetic resonance imaging is discussed and evaluated.
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February 2020

Functional and perioperative outcomes in elderly men after robotic-assisted radical prostatectomy for prostate cancer.

World J Urol 2020 Nov 7;38(11):2791-2798. Epub 2020 Feb 7.

Division of Urology, Department of Surgery, Centre hospitalier de l'université de Montréal (CHUM), Montreal, QC, Canada.

Purpose: We aimed to compare postoperative functional outcomes following robotic-assisted radical prostatectomy (RARP) in elderly men with localized prostate cancer.

Methods: A retrospective review of a prospectively maintained database of men who underwent RARP between January 2007 and November 2018 was performed. Patients over 65 years of age were selected (N = 302) and then stratified by age group: 66-69 years old (N = 214) and ≥ 70 years old (N = 88). Full continence was defined as strict 0-pad per day usage. Preoperative potency included those with a Sexual Health Inventory for Men score ≥ 17. Preoperative and postoperative functional outcomes were assessed. Kaplan-Meier analysis was used to estimate time to recovery of continence in both groups.

Results: Both groups had comparable preoperative parameters. Continence rates at 1, 3, 6, 9, 12, 18 and 24 months in the 66-69-year-old group were 6%, 34%, 61%, 70%, 74%, 80% and 87%, respectively. Comparatively in the ≥ 70-year-old group, continence rates were significantly lower at all time points (3%, 22%, 50%, 56%, 66%, 69% and 75%, respectively). Men in the 66-69-year-old group were significantly more likely to be continent after RARP when compared to patients 70 years of age and above [(Hazards ratio (HR) 0.73; 95%confidence interval 0.54-0.97, (p = 0.035)].

Conclusion: Our results suggest that RARP is feasible in elderly patients. Nevertheless, elderly patients in the ≥ 70-year-old group had significantly inferior postoperative continence rates compared to patients aged 66-69 years. Such information is valuable when counselling men during preoperative RARP planning to ensure that they have realistic postoperative expectations.
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http://dx.doi.org/10.1007/s00345-020-03096-0DOI Listing
November 2020

National discrepancies in residency training of open simple prostatectomy for benign prostatic enlargement: Redefining our gold standard.

Can Urol Assoc J 2020 Jun;14(6):182-186

Division of Urology, Centre hospitalier de l'Université de Montréal, Université de Montréal, Montreal, QC, Canada.

Introduction: In light of the recent Canadian Urological Association (CUA) and other urological associations' (America Urological Association, European Association of Urology) recommendations for the treatment of benign prostate hyperplasia (BPH) with lower urinary tract symptoms (LUTS), open simple prostatectomy (OSP) remains the recommended approach for large prostates with measured volumes over 80 cc. We sought to assess the current state of OSP and other BPH surgical training across Canadian urology residency programs and the use of guideline-recommended imagery prior to BPH surgery.

Methods: A survey was distributed among Canadian urology program directors in June 2019. We identified the various surgical modalities available for the treatment of BPH offered by each program and obtained the annual number of OSP performed at each academic residency program. Additionally, we evaluated if preoperative transrectal ultrasound (TRUS) of the prostate was routinely performed to obtain the prostate volume during patient counselling, as recommended by 2018 CUA guidelines.

Results: All 13 program directors from the Canadian urology programs responded to our survey. OSP and monopolar transurethral resection of the prostate (TURP) remain the most common across programs and are practiced in all centers. Greenlight photo-vaporization, bipolar TURP, holmium laser enucleation of the prostate, and robot-assisted simple prostatectomy were practiced in 76.8%, 69.2%, 23.1%, and 23.1% of centers, respectively. The mean number of OSP per academic training program was 4.7 cases annually. Moreover, only five (38%) academic centers routinely performed a preoperative TRUS to evaluate prostate volume for BPH counselling.

Conclusions: Although recognized and referenced as the BPH gold standard for the treatment of prostates over 80 cc, Canadian urology trainees' annual OSP exposure remains extremely limited. Considering the degree of importance given (category A) to the direct observation (of a minimum of five) of this intervention during residency training in the new Royal College's practice guidelines, it may be unrealistic to reach these national standards considering the annual case OSP volumes in Canadian academic urology faculties.
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http://dx.doi.org/10.5489/cuaj.6242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654682PMC
June 2020

Transfusion rates after 800 Aquablation procedures using various haemostasis methods.

BJU Int 2020 04 24;125(4):568-572. Epub 2020 Jan 24.

Department of Urology, University of Southern California, Los Angeles, CA, USA.

Objective: To determine if athermal methods are as effective in preventing blood transfusions as the use of cautery across various prostate volumes following prostate tissue resection for benign prostatic hyperplasia using Aquablation.

Patients And Methods: The current commercial AQUABEAM robot that performs Aquablation therapy was first used in 2014. Since then numerous clinical studies have been conducted in various countries; Australia, Canada, Germany, India, Lebanon, Spain, New Zealand, United Kingdom, and the United States. All of the clinical trial data since 2014 were pooled with the early commercial procedures from France, Germany, and Spain to determine the effectiveness of haemostatic techniques in reducing the transfusion rate in patients after Aquablation.

Results: In all, 801 patients were treated with Aquablation therapy from 2014 to early 2019. The mean (SD, range) prostate volume was 67 (33, 20-280) mL and 31 (3.9%) transfusions were reported. The largest contributing factor to transfusion risk was prostate size and method of traction. There was an increasing risk of transfusions in larger prostates when robust traction using a catheter-tensioning device (CTD) without cautery was used, ranging from 0.8% to 7.8% in prostates ranging from 20 to 280 mL. However, when standard traction (taping the catheter to the leg, gauze knot synched up to the meatus, or no traction at all) was used and where the surgeon performed bladder neck cautery only when necessary, the risk of transfusion was 1.4-2.5% in prostates ranging from 20 to 280 mL.

Conclusions: While the athermal subgroup with robust traction with a CTD had comparable transfusion rates for smaller prostates, the risk increased significantly as prostate volume increased. With standard traction methods and selective bladder neck cautery, the risk of transfusion was reduced to 1.9% across all prostate sizes.
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http://dx.doi.org/10.1111/bju.14990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187336PMC
April 2020

Standardization of 532 nm Laser Terminology for Surgery in Benign Prostatic Hyperplasia: A Systematic Review.

J Endourol 2020 02 30;34(2):121-127. Epub 2020 Jan 30.

Department of Urology, Weill Cornell Medical College/New York Presbyterian, New York, New York.

The use of GreenLight™ laser technology to remove the prostatic transitional zone transurethrally has grown considerably in recent years. This increased utilization has resulted in an increase in the number of terms that are used to describe various laser techniques. Variable terminology complicates literature analysis and publication, which can cause confusion when performing reviews and comparisons of the techniques in the available literature. It has therefore become necessary to simplify and standardize terminology used to describe transurethral prostate debulking procedures using the 532 nm laser to simplify communication on these techniques. We conducted a search on September 17, 2019, in the following databases: Ovid MEDLINE, Ovid EMBASE, and PubMed. Of the 1115 unique records found in our database search, a total of 27 articles were selected for inclusion. Of the 16 search terms used, we found that 4 terms could be used to describe the fundamental technique associated with each search term. These terms include "vaporization," "vaporesection," "vapoenucleation," and "enucleation." Standardizing terminology leads to an efficient consolidation of terms based on the above outcomes. This will streamline the literature search process for future publications and facilitate comparison of varying techniques.
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http://dx.doi.org/10.1089/end.2019.0756DOI Listing
February 2020

Favorable preservation of erectile function after prostate brachytherapy for localized prostate cancer.

Brachytherapy 2020 Mar - Apr;19(2):222-227. Epub 2019 Dec 16.

Division of Urology, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada.

Purpose: We analyzed the rate of preserved potency after prostate brachytherapy (PB) with radioactive seeds and the impact of patient comorbidities on post-PB erectile dysfunction (ED).

Methods: We included 627 patients who were assessed for pre- and postimplant potency between 2005 and 2017. Assessment was based on the Common Terminology Criteria for Adverse Events Scale (CTCAEs). Logistic regression models were used to assess clinical predictors of preserved potency after PB defined as having sufficient erections for sexual activity with or without the need of oral pharmacologic assistance. Covariates included age, diabetes (DM), hypertension (HTN), dyslipidemia (DLP), coronary artery disease (CAD), International Prostate Symptom Score (IPSS), prostate volume, and Cancer of the Prostate Risk Assessments (CAPRA) score. Patients on androgen deprivation therapy or using five alpha reductase inhibitors were excluded from analyses.

Results: Post-PB potency was assessed at an average of 6 months (n = 627), 1 year (n = 538), 2 years (=440), 4 years (n = 272), and 5 years (n = 124). At 2 and 5 years, post-PB potency was preserved in 87% and 84% of patients, respectively. When adjusting for all available covariates, advanced age, pre-PB potency, and the presence of vascular comorbidities (HTN, DM, and DLP) were all predictors of potency at 2 years after PB (all p < 0.01). When performing a sensitivity analysis for vascular comorbidities, the presence of DM had the strongest impact on ED than either HTN or DLP (p < 0.01).

Conclusion: More than 84% of patients had preserved potency 5 years after PB. Advanced age, pre-PB potency, and vascular comorbidities had a statistically significant impact on potency after PB.
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http://dx.doi.org/10.1016/j.brachy.2019.11.003DOI Listing
December 2020

The role of photovaporization of the prostate in small volume benign prostatic hyperplasia and review of the literature.

Asian J Urol 2019 Oct 25;6(4):353-358. Epub 2019 Jan 25.

Department of Urology, Weill Cornell Medical College/New York Presbyterian, New York, NY, USA.

Objective: Our objective was to characterize the safety and efficacy of the 180 W XPS-GreenLight laser in men with lower urinary tract symptoms secondary to a small volume benign prostatic hyperplasia (BPH).

Methods: A retrospective analysis was performed for all patients who underwent 180 W XPS-laser photoselective vaporization of the prostate (PVP) vaporization of the prostate between 2012 and 2016 at two-tertiary medical centers. Data collection included baseline comorbidities, disease-specific quality of life scores, maximum urinary flow rate (Q), postvoid residual (PVR), complications, prostate volume and prostate-specific antigen (PSA). The secondary endpoints were the incidence of intraoperative and postoperative adverse events. Complications were stratified using the Clavien-Dindo grading system up to 90 days after surgery.

Results: Mean age of men was 67.8 years old, with a mean body mass index of 29.7 kg/m. Mean prostate volume as measured by transrectal ultrasound was 29 mL. Anticoagulation use was 47% and urinary retention with catheter at time of surgery was 17%. Mean hospital stay and catheter time were 0.5 days. Median follow-up time was 6 months with the longest duration of follow-up being 22.5 months (interquartile range, 3-22.5 months). The International Prostate Symptom Score improved from 22.8 ± 7.0 at baseline to 10.7 ± 7.4 ( < 0.01) and 6.3 ± 4.4 ( < 0.01) at 1 and 6 months, respectively. The Q improved from 7.70 ± 4.46 mL/s at baseline to 17.25 ± 9.30 mL/s ( < 0.01) and 19.14 ± 7.19 mL/s ( < 0.001) at 1 and 6 months, respectively, while the PVR improved from 216.0 ± 271.0 mL preoperatively to 32.8 ± 45.3 mL ( < 0.01) and 26.2 ± 46.0 mL ( < 0.01) at 1 and 6 months, respectively. The PSA dropped from 1.97 ± 1.76 ng/mL preoperatively to 0.71 ± 0.61 ng/mL ( < 0.01) and 0.74 ± 0.63 ng/mL at 1 and 6 months, respectively. No patient had a bladder neck contracture postoperatively and no capsular perforations were noted intraoperatively.

Conclusion: The 180 W GreenLight XPS system is safe and effective for men with small volume BPH. PVP produced improvements in symptomatic and clinical parameters without any safety concern. It represents a safe surgical option in this under studied population.
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http://dx.doi.org/10.1016/j.ajur.2019.01.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6872824PMC
October 2019

Survival outcomes of radical prostatectomy vs. external beam radiation therapy in prostate cancer patients with Gleason Score 9-10 at biopsy: A population-based analysis.

Urol Oncol 2020 03 23;38(3):79.e9-79.e14. Epub 2019 Oct 23.

Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, Quebec, Canada.

Purpose: Gleason Score (GS) 9-10 prostate cancer is associated with particularly adverse oncological outcomes and the optimal treatment is unknown. Therefore, cancer-specific mortality (CSM) rates after radical prostatectomy (RP) ± adjuvant radiation therapy (aRT) vs. external beam radiation therapy (EBRT) were tested.

Methods: Within the Surveillance, Epidemiology, and End Results database (2004-2015), 17,897 clinically localized prostate cancer patients with biopsy GS 9-10 were identified who either received RP ± aRT or EBRT. Temporal trends, cumulative incidence plots and multivariable competing-risks regression analyses were used after propensity score matching. Sensitivity analyses were performed according to primary treatment type (RP only vs. EBRT).

Results: Of all, 8,890 (49.7%) underwent EBRT vs. 9,007 (50.3%) underwent RP. Of those, 2,584 (28.7%) received aRT. No significant change in treatment assignment was recorded over time. In cumulative incidence smoothed plots, 10 year CSM rates were 19.9% vs. 19.6% (P = 0.3) and 10 year other-cause mortalityrates were 11.5% vs. 31.2%, respectively, in RP vs. EBRT patients (P < 0.001). In multivariable competing-risks regression analyses, RP did not reach independent predictor status of lower CSM (hazard ratio (HR): 0.93, P = 0.2). In sensitivity analyses within RP only vs. EBRT patients, RP represented an independent predictor of lower CSM (HR: 0.76, P < 0.001).

Conclusions: In biopsy GS 9-10 patients, no CSM differences were observed after RP ± aRT vs. EBRT. However, in patients in whom RP did not have to be combined with aRT, RP seems to be associated with a minor improvement in cancer-specific survival compared to EBRT. This applied to the majority of GS 9-10 RP patients.
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http://dx.doi.org/10.1016/j.urolonc.2019.09.015DOI Listing
March 2020