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Re: Contemporary Use of Initial Active Surveillance among Men in Michigan with Low-Risk Prostate Cancer
PROSTATE CANCER
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Abstract available at http://jurology.com/ Editorial Comment: There have been a number of conflicting reports regarding the relationship of vasectomy and prostate cancer risk. In the early 1990s a report from the Health Professionals Follow-up Study and 1 other study demonstrated an increased risk of prostate cancer in men undergoing vasectomy. Several subsequent studies refuted the finding, and much of the observation was attributed to detection bias in that men who undergo vasectomy are more likely to receive followup medical and urological care. This report and updated followup demonstrate an increased risk of prostate cancer. However, on subset analysis vasectomy was associated with an increased risk of high grade prostate cancer and lethal prostate cancer but not low grade disease. The authors conclude that the observation rules out the possibility of detection bias as prostate cancer mortality would not be affected by such bias. In fact, in separately analyzing men who were heavily screened the effect of vasectomy on high grade prostate cancer persisted. Despite the observation, the study findings remain controversial. In evaluating the relative risk of prostate cancer following vasectomy it does not appear to change with time when comparing men who underwent vasectomy more or less than 23 years ago. If truly a causal event, I would expect the risk to increase with time. The authors do not present the relationship with time as a continuous variable, so it is difficult to assess. There is also no relationship of vasectomy with hormone levels or risk of sexually transmitted disease in this cohort, so a mechanism is not evident or proposed. In the end the odds ratio is marginal, and the increase in absolute risk of lethal prostate cancer is quite small. I do not believe this study will change our practice of vasectomy, but the issue of prostate cancer risk should probably be discussed with men at the time of consent. Samir S. Taneja, MD
Suggested Reading Holt SK, Salinas CA and Stanford JL: Vasectomy and the risk of prostate cancer. J Urol 2008; 180: 2565. Lynge E: Prostate cancer is not increased in men with vasectomy in Denmark. J Urol 2002; 168: 488. Lesko SM, Louik C, Vezina R et al: Vasectomy and prostate cancer. J Urol 1999; 161: 1848. Sidney S: Vasectomy and the risk of prostatic cancer and benign prostatic hypertrophy. J Urol 1987; 138: 795.
Re: Contemporary Use of Initial Active Surveillance among Men in Michigan with Low-Risk Prostate Cancer P. R. Womble, J. E. Montie, Z. Ye, S. M. Linsell, B. R. Lane and D. C. Miller; Michigan Urological Surgery Improvement Collaborative Department of Urology, Dow Division of Health Services Research, University of Michigan Health System, Ann Arbor and Spectrum Health Medical Group Urology, Michigan State University College of Human Medicine, Grand Rapids, Michigan Eur Urol 2014; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: This important study demonstrates that attitudes about surveillance are changing among American urologists. The authors have established a collaborative registry of community based urology practices across the state of Michigan. For this study they identified men diagnosed with low risk prostate cancer within those practices who would have qualified for surveillance based on disease characteristics. The authors report that 49% of those men were placed on surveillance but they note significant geographic variability in surveillance application. This geographic variability parallels recent reports of prostate specific antigen testing and prostate cancer treatment, suggesting that practice patterns are often based on physician preference rather than guidelines or consensus recommendations. The authors also demonstrate that the practice of surveillance is quite variable, with only a subset of men undergoing followup biopsy
LAPAROSCOPY/NEW TECHNOLOGY
129
within the first year. This finding is a concern, as adaptation of surveillance and preservation of acceptable clinical outcomes from surveillance will require consensus in the proper methodology for practice. Samir S. Taneja, MD
Suggested Reading Filson CP, Schroeck FR, Ye Z et al: Variation in use of active surveillance among men undergoing expectant treatment for early stage prostate cancer. J Urol 2014; 192: 75. Loeb S, Berglund A and Stattin P: Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol 2013; 190: 1742.
Laparoscopy/New Technology Re: Lateral Temperature Spread of Monopolar, Bipolar and Ultrasonic Instruments for Robot-Assisted Laparoscopic Surgery L. J. Hefermehl, R. A. Largo, T. Hermanns, C. Poyet, T. Sulser and D. Eberli Division of Urology, University Hospital Zurich, Zurich, Switzerland BJU Int 2014; 114: 245e252.
Abstract available at http://jurology.com/ Editorial Comment: This is a valuable well-done study that independently assesses the lateral thermal changes associated with activation of the various energy based robotic instruments. Of course, these findings are particularly relevant to robotic prostatectomy. I cannot review all of the data presented in that each instrument was tested in various activation scenarios. Suffice it to say that when activated for 1 second at 30 watts (the most common clinical settings), the robotic scissors performed the worst, with the temperature increasing above 45C as far as 2.6 mm from the instrument tip. The Maryland bipolar instrument had a 1.5 mm spread, and the HarmonicÒ scalpel had the lowest spread at 1.1 mm. When it comes to possible application near the neurovascular bundles, the automatic robotic PKSÔ and LigaSureÔ instruments probably should be avoided as well, given that they perform no better than hot shears, with lateral temperature increases above 45C of 2.5 and 2.8 mm, respectively. Interestinglydand a good clinical pearldthe tissue temperature increase associated with each instrument can be mitigated by placing a second instrument alongside the energy device and touching the tissue to act as a heat sink. The thermal spread decreased by 0.5 to 1.0 mm for the instruments tested using this maneuver. Jeffrey A. Cadeddu, MD
Urological Oncology: Testis Cancer and Advances in Oncologic Therapy Re: Testicular Cancer Incidence to Rise by 25% in Europe? Model-Based Predictions in 40 Countries Using Population-Based Registry Data ranger, A. Flechon, C. Le Cornet, J. Lortet-Tieulent, D. Forman, R. Be € B. Fervers, J. Schuz and F. Bray Cancer Sections of Environment and Radiation, and Cancer Information, International Agency for Research on Cancer, and Unite on Be rard, Lyon and Universite Claude Bernard Lyon 1, et Environnement and Centre de Lutte Contre le Cancer, Centre Le Villeurbanne, France
128
Abstract available at http://jurology.com/ Editorial Comment: There have been a number of conflicting reports regarding the relationship of vasectomy and prostate cancer risk. In the early 1990s a report from the Health Professionals Follow-up Study and 1 other study demonstrated an increased risk of prostate cancer in men undergoing vasectomy. Several subsequent studies refuted the finding, and much of the observation was attributed to detection bias in that men who undergo vasectomy are more likely to receive followup medical and urological care. This report and updated followup demonstrate an increased risk of prostate cancer. However, on subset analysis vasectomy was associated with an increased risk of high grade prostate cancer and lethal prostate cancer but not low grade disease. The authors conclude that the observation rules out the possibility of detection bias as prostate cancer mortality would not be affected by such bias. In fact, in separately analyzing men who were heavily screened the effect of vasectomy on high grade prostate cancer persisted. Despite the observation, the study findings remain controversial. In evaluating the relative risk of prostate cancer following vasectomy it does not appear to change with time when comparing men who underwent vasectomy more or less than 23 years ago. If truly a causal event, I would expect the risk to increase with time. The authors do not present the relationship with time as a continuous variable, so it is difficult to assess. There is also no relationship of vasectomy with hormone levels or risk of sexually transmitted disease in this cohort, so a mechanism is not evident or proposed. In the end the odds ratio is marginal, and the increase in absolute risk of lethal prostate cancer is quite small. I do not believe this study will change our practice of vasectomy, but the issue of prostate cancer risk should probably be discussed with men at the time of consent. Samir S. Taneja, MD
Suggested Reading Holt SK, Salinas CA and Stanford JL: Vasectomy and the risk of prostate cancer. J Urol 2008; 180: 2565. Lynge E: Prostate cancer is not increased in men with vasectomy in Denmark. J Urol 2002; 168: 488. Lesko SM, Louik C, Vezina R et al: Vasectomy and prostate cancer. J Urol 1999; 161: 1848. Sidney S: Vasectomy and the risk of prostatic cancer and benign prostatic hypertrophy. J Urol 1987; 138: 795.
Re: Contemporary Use of Initial Active Surveillance among Men in Michigan with Low-Risk Prostate Cancer P. R. Womble, J. E. Montie, Z. Ye, S. M. Linsell, B. R. Lane and D. C. Miller; Michigan Urological Surgery Improvement Collaborative Department of Urology, Dow Division of Health Services Research, University of Michigan Health System, Ann Arbor and Spectrum Health Medical Group Urology, Michigan State University College of Human Medicine, Grand Rapids, Michigan Eur Urol 2014; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: This important study demonstrates that attitudes about surveillance are changing among American urologists. The authors have established a collaborative registry of community based urology practices across the state of Michigan. For this study they identified men diagnosed with low risk prostate cancer within those practices who would have qualified for surveillance based on disease characteristics. The authors report that 49% of those men were placed on surveillance but they note significant geographic variability in surveillance application. This geographic variability parallels recent reports of prostate specific antigen testing and prostate cancer treatment, suggesting that practice patterns are often based on physician preference rather than guidelines or consensus recommendations. The authors also demonstrate that the practice of surveillance is quite variable, with only a subset of men undergoing followup biopsy
LAPAROSCOPY/NEW TECHNOLOGY
129
within the first year. This finding is a concern, as adaptation of surveillance and preservation of acceptable clinical outcomes from surveillance will require consensus in the proper methodology for practice. Samir S. Taneja, MD
Suggested Reading Filson CP, Schroeck FR, Ye Z et al: Variation in use of active surveillance among men undergoing expectant treatment for early stage prostate cancer. J Urol 2014; 192: 75. Loeb S, Berglund A and Stattin P: Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol 2013; 190: 1742.
Laparoscopy/New Technology Re: Lateral Temperature Spread of Monopolar, Bipolar and Ultrasonic Instruments for Robot-Assisted Laparoscopic Surgery L. J. Hefermehl, R. A. Largo, T. Hermanns, C. Poyet, T. Sulser and D. Eberli Division of Urology, University Hospital Zurich, Zurich, Switzerland BJU Int 2014; 114: 245e252.
Abstract available at http://jurology.com/ Editorial Comment: This is a valuable well-done study that independently assesses the lateral thermal changes associated with activation of the various energy based robotic instruments. Of course, these findings are particularly relevant to robotic prostatectomy. I cannot review all of the data presented in that each instrument was tested in various activation scenarios. Suffice it to say that when activated for 1 second at 30 watts (the most common clinical settings), the robotic scissors performed the worst, with the temperature increasing above 45C as far as 2.6 mm from the instrument tip. The Maryland bipolar instrument had a 1.5 mm spread, and the HarmonicÒ scalpel had the lowest spread at 1.1 mm. When it comes to possible application near the neurovascular bundles, the automatic robotic PKSÔ and LigaSureÔ instruments probably should be avoided as well, given that they perform no better than hot shears, with lateral temperature increases above 45C of 2.5 and 2.8 mm, respectively. Interestinglydand a good clinical pearldthe tissue temperature increase associated with each instrument can be mitigated by placing a second instrument alongside the energy device and touching the tissue to act as a heat sink. The thermal spread decreased by 0.5 to 1.0 mm for the instruments tested using this maneuver. Jeffrey A. Cadeddu, MD
Urological Oncology: Testis Cancer and Advances in Oncologic Therapy Re: Testicular Cancer Incidence to Rise by 25% in Europe? Model-Based Predictions in 40 Countries Using Population-Based Registry Data ranger, A. Flechon, C. Le Cornet, J. Lortet-Tieulent, D. Forman, R. Be € B. Fervers, J. Schuz and F. Bray Cancer Sections of Environment and Radiation, and Cancer Information, International Agency for Research on Cancer, and Unite on Be rard, Lyon and Universite Claude Bernard Lyon 1, et Environnement and Centre de Lutte Contre le Cancer, Centre Le Villeurbanne, France