BACKGROUND:Patients with postradical prostatectomy (RP) prostate-specific antigen (PSA) persistence (PPP) have been grouped with patients experiencing biochemical recurrence (BCR) in guidelines and clinical trials, potentially masking their distinct, unfavorable outcomes. The objective of this study was to determine whether patients with PPP constitute a unique, high-risk population. METHODS:The authors conducted a retrospective study of patients with prostate cancer undergoing RP (between January l, 2013 and June 30, 2024) using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry. Post-RP status was defined as no evidence of disease (NED; never developed detectable PSA), PPP (first PSA remained detectable), and BCR (initially undetectable PSA with PSA ≥0.2 ng/mL later). The following differences were quantified: (1) pre-RP characteristics, (2) pathologic characteristics at RP, (3) subsequent treatment patterns, and (4) differences in mortality outcomes based on postoperative PSA status. RESULTS:Of 15,390 patients with who had a follow-up of 4.0 years (interquartile range, 2.4-4.6 years), 11,019 still had NED, 1919 had PPP, and 2452 developed BCR. Patients who had PPP demonstrated a higher risk pre-RP and post-RP characteristics compared with those who had NED or BCR on unadjusted and adjusted comparisons, with differences that were both statistically significant and clinically meaningful. Patients who had PP had significantly higher PSA values before secondary treatment compared with those who had BCR (median PSA, 0.73 vs. 0.28 ng/mL, respectively; p < .001). The 5-year all-cause mortality rate was 2.5% (95% confidence interval, 2.1%-2.9%) for patients with initially undetectable PSA (NED and BCR combined) and 5.7% (95% confidence interval, 4.3%-5.7%) for patients with PPP (p < .001). CONCLUSIONS:One in eight patients who undergo prostatectomy experience PPP. These patients constitute a unique, high-risk population distinct from patients who have NED and BCR. Clinical trials addressing optimal treatment and intensity for these at-risk patients are critically warranted.
Background and Objectives Single Port (SP) robotic radical prostatectomy (RARP) has been increasingly used, with Extraperitoneal (EP) and Transvesical (TV) approaches being the most common. This study sought to describe the multi-institutional clinical experience of EP and TV SP-RARP. Materials and Methods A retrospective review was conducted using the prospectively maintained, Institutional Review Board-approved database of the SP Advanced Research Consortium (SPARC) to identify all consecutive patients who underwent EP or TV SP-RARP between 2019 and 2025. A 1:1 propensity score-matched comparison analysis was performed based on the age, prostate volume, PSA levels, and ISUP Grade Groups on the preoperative prostate biopsy. Results and Limitations A total of 2230 patients were reviewed, which included 1699 (76.2%) EP and 531 (23.8%) TV SP-RARP. Following propensity score-matched analysis, 884 patients were included, with 442 being analyzed from each group. History of previous abdominal surgery was more prevalent in the TV cohort (EP 33% vs TV 49.5%, SMD = 0.342). All procedures were completed successfully, with similar operative times (median, 184 vs 192 min, p = 0.733), risk of intraoperative complications (0.6% vs 1%, p = 0.307), and positive surgical margin status (pT2, 13.3% vs 14.7%, p = 0.070). Postoperatively, the SP-TV approach was associated with higher rates of same-day discharges (60.6% vs 78.2%, p < 0.001), a shorter Foley catheter duration (median, 7 vs 5 d, p < 0.001), with no differences in the incidence of major complications (3.2% vs 1.6%, p = 0.185). With 42.3% of patients achieving immediate urine continence following TV SP-RARP, the regionalized technique conferred improved early continence recovery at both 6 wk (44% vs 52.9%, p < 0.001), 3 mo (69.7% vs 79.1%, p = 0.040), and 6 mo (77.9% vs 87.2%, p < 0.001). At 12 mo, satisfactory erectile function was reported in 85.7% and 88.4% of the SP EP and TV groups, respectively (p = 0.174). At a median follow-up duration of 10 mo, biochemical recurrence rates were similar between the two groups (3.1% vs 3.6%, p = 0.678). Limitations of this study included the retrospective study design of the relatively novel surgical techniques, with limited long-term follow-up data. Conclusion TV SP-RARP offers notable advancements in patient comfort, featuring higher rates of same-day discharges, reduced opioid use, shorter Foley catheter duration, and early recovery of urine continence, whilst maintaining comparable perioperative safety and oncological adequacy to EP SP-RARP.
BACKGROUND Genitourinary sarcomas include testicular sarcomas and are the most common subtype of sarcoma within the genitourinary system. Undifferentiated pleomorphic sarcoma is a subtype of soft tissue sarcomas that may affect the extremities and retroperitoneum. However, the presence within the testicle is rare. Here, we present a case of an undifferentiated testicular pleomorphic sarcoma, which will explore the presentation and treatment of a rare type of testicular cancer. CASE SUMMARY Here we present a 56-year-old male who comes to the urology clinic for left testicular swelling. The patient then underwent left radical orchiectomy via an inguinal approach for a left testicular mass seen on examination and on scrotal ultrasound. Pathology revealed undifferentiated pleomorphic sarcoma (Federation of the French Cancer Centres grade 3), 9.5 cm in size, and it was limited to the testicle. The surgical margins were negative. A follow-up positron emission tomography computed tomography scan was obtained, which showed no evidence of hypermetabolic lymph nodes or masses in the abdomen or pelvis. CONCLUSION Testicular sarcomas are a rare type of soft tissue sarcoma. The standard treatment of the testicular mass usually begins with radical inguinal orchiectomy. Patients with scrotal sarcomas are at high risk of local and distant recurrence, emphasizing the importance of surgical excision and wide margins. There is little studied regarding the integration of radiotherapy and chemotherapy for these cases as neoadjuvant or adjuvant therapies. This case highlights the presentation and treatment of a patient with a rare phenotype of testicular pleomorphic sarcoma treated by radical inguinal orchiectomy. In this study, our patient continued without nodal or distant disease in his initial positron emission tomography computed tomography scan after surgery.
OBJECTIVE:To evaluate the impact on patient-reported outcomes of the efforts by the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) initiative to reduce postoperative opioid use after ureteroscopy. METHODS:We evaluated MUSIC ROCKS patients with complete prescription and PRO data. PROMIS pain intensity and interference scores were compared between opioid and non-opioid users using multivariable regression models. A sub-analysis compared opioid users discharged with multimodal therapy and then required rescue opioids versus those given opioid at discharge. RESULTS:Opioid prescription rates after ureteroscopy declined from 83% in 2016 to 13% in 2023. Of the 405 opioid-naïve ureteroscopy cases; 23% reported opioid use within 7-10 days post-op. At 7-10 days after surgery, patients taking opioids had worse pain intensity and pain interference than those who had not. However, there were no statistically significant differences in PROs between those prescribed opioid at discharge versus those who required rescue opioid. Multivariable predictors of both pain intensity and interference included postoperative opioid use at 7-10 days, postoperative stent placement and preoperative stent use. CONCLUSION:Opioid use after ureteroscopy has declined sharply in Michigan. We did not see evidence that PROs differed between patients discharged opioid-free who later required rescue opioids and those discharged with opioids, supporting the use of multimodal regimens. Postoperative stent use, however, was a key predictor of pain, highlighting its modifiable impact on outcomes.
The treatment of metastatic hormone-sensitive prostate cancer (mHSPC) has evolved in recent years towards combination therapy, enhancing survival outcomes when compared with androgen deprivation therapy (ADT) alone. However, many patients who are eligible for combination therapy are still receiving ADT monotherapy, and a significant proportion of those treated with doublet combinations still experience suboptimal outcomes. Furthermore, the value of adding docetaxel to an androgen receptor pathway inhibitor (ARPI)/ADT doublet in mHSPC has not been delineated, particularly in patients with low-volume disease, and chemotherapy toxicity and tolerability remain a major concern for patients. This review addresses the significant unmet need for additional or novel treatment strategies for mHSPC, utilizing prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT) in a combination regimen that uses a non-chemotherapeutic approach for the treatment of mHSPC. PSMA-targeted RLT has been shown to improve survival outcomes in patients with metastatic castration-resistant prostate cancer (mCRPC) previously treated with ARPIs +/- taxanes and is now under evaluation for the treatment of mHSPC, given its demonstrated success in the mCRPC space. Thus, continued education on RLT and its use for patients with mHSPC is important to optimize patient care. This review provides a brief outline of the mHSPC treatment landscape, focusing on the challenges and unique considerations faced by healthcare professionals when treating these patients. We also evaluate the potential role of RLT in surmounting these challenges, discussing potential barriers and solutions to its integration as a treatment for mHSPC.
