Opinion

Metabolic syndrome is associated with increased cancer risk and progression at almost all sites, including the prostate in high-stage prostate cancer, but several reports have described an inverse relationship between metabolic syndrome and its components and low-stage incident prostate cancer. Here, Hammarsten et al. hypothesize that the inverse link between metabolic syndrome and its components and low-stage incident prostate cancer might simply be the result of bias mechanisms.

The introduction of immune checkpoint inhibition has improved the outcomes of a subset of patients with muscle-invasive bladder cancer (MIBC); however, the majority of patients fail to respond to this approach. In this perspective, the authors describe the evidence for use of radiotherapy in combination with immune checkpoint inhibition to enhance the immunogenicity of patients' tumours and therefore enhance responsiveness to immune checkpoint inhibition in patients with advanced-stage MIBC.

Reichard and Klein present clinical and molecular data that stand against removing the cancer descriptor from Gleason score 3 + 3 = 6 prostate cancer. They argue that the evidence of a lack of malignancy is inconclusive and that a change in classification might result in poor patient outcomes.

Asia is an emerging centre of growth in the field of urology owing to large and varied patient populations, the availability of a trained workforce, the use of English as a common language, and overall low costs. Asian urology has immense potential to expand in areas in which it currently lags behind, especially research. In this Perspective, Kumar uses a strength–weakness–opportunities–threats (SWOT) analysis to discuss the current state of urology in Asia and comment on the future direction of this field in this region.

Despite large numbers of patients being affected by stones, a surprising lack of knowledge exists on the relevance of stone compositions and pathological features to the outcomes of patients with stones. Here authors describe the potential of new technologies such as high-resolution endoscopes, and micro-CT imaging to address this lack of knowledge.

Miah and colleagues discuss differences between Gleason pattern 3 and pattern 4 prostate cancer that make the designation of pattern 3 disease as a lethal disease uncertain and argue in favour of dropping the label cancer for Gleason score 3 + 3 = 6 tumours.

Central sensitization, resulting in a disproportionately painful response to peripheral signals of a regular intensity has been implicated in a variety of chronic pain syndromes, including interstitial cystitis. In this Perspective, the authors describe a potential role of central sensitization in idiopathic overactive bladder, a condition characterized by altered sensations of urinary urgency with no apparent pathological alterations.

Selection of treatment for a patient with prostate cancer is often based on age and life expectancy. However, life expectancy estimates are often calculated solely on the basis of chronological age, overlooking comorbid conditions and their severity, which affect life expectancy. Here, the authors discuss how factors other than chronological age should be used to assess life expectancy and enable the most appropriate treatment options to be selected. Older, healthy patients might be able to tolerate more-aggressive treatments than their age might indicate, and younger patients with numerous comorbid conditions could avoid harsh therapy if inappropriate.

Cancer evolution is often depicted using a tree model and many current therapies target gene mutations mapped to the tree trunk. Here, Wei and Hsieh propose a novel paradigm—the river model—and examine how this model might describe phenotypically convergent events to better guide effective cancer control in renal cell carcinoma and overcome treatment-resistance that eventually develops in most patients.

Global interest in testosterone deficiency in men and its treatment with testosterone therapy has increased, but practical aspects of care remain confusing to many practitioners. Here, Aversa and Morgentaler describe the symptoms, signs, and diagnosis of testosterone deficiency and discuss the options for testosterone therapy and treatment monitoring, along with its clinical benefits.

Many patients experience impaired erectile function after prostate cancer treatment and struggle to resume a satisfying sexual relationship. In this Perspectives article, Walker, Robinson and Wassersug provide healthcare professionals with recommendations to facilitate successful sexual recovery and the best outcome for patients and their partners.

Testosterone supplementation therapy for men with hypogonadism remains controversial. The definition of hypogonadism in older men is vague and many of the associated symptoms could be considered to be physiological and not requiring treatment. In this Perspectives, Laurence Klotz considers the evidence—or lack thereof—to support the safety of TST in men with and without prostate cancer, and recommends caution in its use.

The use of robot-assisted surgery for treatment of genitourinary malignancies is increasing dramatically. Kaye and colleagues argue that consumerism, rather than surgical outcomes, drives the adoption of this expensive technology. Robotics use should be targeted to surgical situations where clinical benefit or cost-effectiveness can be demonstrated.

New androgen-receptor-targeting drugs, such as enzalutamide, provide a substantial survival benefit for patients with castration-resistant prostate cancer, but treatment resistance has been reported. In this Perspectives article, Claessens and colleagues describe the mechanisms underlying the development of such resistance and discuss their clinical relevance.

Jannini et al. describe the evidence supporting the concept of the clitourethrovaginal (CUV) complex, and the overlap with the properties of the elusive G-spot. Consideration of the intricate anatomical relationships involved in female sexual arousal and orgasm could help to avoid damage to the CUV complex during surgery.

Historically, the use of testosterone supplementation therapy (TST) for hypogonadism in men with prostate cancer has been limited by concerns that such treatment might cause progression of this androgen-dependent cancer; however, the contemporary literature indicates that TST in men with prostate cancer can be safe and, contrary to traditional thinking, that TST might actually reduce the risk of prostate cancer development. In this opinion piece, Larry Lipshultz and colleagues discuss the evidence supporting TST—in contrast with the lack of evidence against this approach—in hypogonodal men with prostate cancer.

Johnson and Irwig discuss a community of biological males who desire emasculation and commonly resort to self-castration, castration by nonmedical professionals, or self-inflicted testicular damage via injections of toxic substances. Urologists should be aware of the growing popularity of these procedures.

BPH–LUTS and erectile dysfunction commonly coexist, and both respond to phosphodiesterase 5 inhibitors. In the opinion of Cellek et al., the underlying pathology of both conditions can be explained by microvascular dysfunction, a vicious cycle of hypoxia, vasoconstriction, altered smooth muscle contractility, and degeneration of autonomic neurons and ganglia.

Urology nursing practice is rapidly developing around the world in response to technological advances, the expansion of service needs, and the increasing subspecialization of urology. Here, Helen Crowe provides unique insight into the successes and challenges of advanced urology nursing and the changing face of this specialty.

Sexual dysfunction—including erectile dysfunction, ejaculatory abnormalities and orgasmic disorders—is a commonly reported adverse effect of prostate cancer therapies. In this Perspectives article, Cormie and colleagues make a case for the use of exercise as a therapeutic option to ameliorate sexual dysfunction in prostate cancer survivors.