News & Views in 2020

Organ-sparing surgery for the management of penile cancer is a dogma underpinned by previous research demonstrating no change in cancer-specific survival in cases of local recurrence. However, a new multicentre study of 897 patients treated with glansectomy for penile cancer challenges this view.

Multiparametric MRI enables early detection of progression and reclassification in patients with low-risk prostate cancer on active surveillance and offers the potential to reduce unnecessary biopsies. However, the reliability and reproducibility of MRI-directed surveillance during follow-up is unclear. A recent study highlights the potential and current shortcomings of this approach.

The PRECISION trial demonstrated the ability of using multiparametric MRI to improve the diagnosis of clinically significant prostate cancer whilst reducing over-diagnosis of clinically insignificant cancer compared with systematic biopsy. Concerns remained about patients who were not biopsied owing to negative scans. A new study applies the PRECISION strategy to a contemporary cohort to answer these concerns.

MRI-guided transurethral ultrasound ablation is an exciting, minimally invasive technology with the potential to provide targeted ablation of prostate cancer tissue. At 3 years, functional outcomes remain good with 76% remaining free from salvage treatment. Future studies using a focal approach may provide evidence for widespread uptake of this technology.

Retzius-sparing prostatectomy is an alternative approach to standard robot-assisted radical prostatectomy. Many surgeons advocate this technique as data suggest that it provides better early functional results than the standard approach without compromising oncological outcomes.

Young-adult cancer survivors report psychosocial distress from infertility. National guidelines recommend pretreatment referrals for sperm cryopreservation, but a study examining use of stored semen among survivors concluded that low uptake might equate to economic unfeasibility. However, examination of sociodemographic factors and psychosocial outcomes suggests that maintaining future opportunities for parenthood might outweigh the ongoing storage costs.

Disruption of the circadian clock has been associated with pathological conditions including obesity, type 2 diabetes mellitus, cancer, depression and neurodegenerative diseases. Disturbed sleep patterns have now been associated with reduced erectile function. The mechanisms behind this effect are unclear but could include hypoxia signalling and low testosterone.

Antimicrobial resistance in Neisseria gonorrhoeae compromises gonorrhoea treatment worldwide. Novel and optimized treatments and/or treatment strategies that effectively eradicate the infection with low selection of resistance are imperative. A new prospective clinical study provides further evidence that resistance-guided treatment of gonorrhoea with single-dose oral ciprofloxacin is efficacious in relevant settings and can reduce the selection pressure for resistance.

Pooled clinical trial data reveal that antibiotics worsen progression-free survival and overall survival in patients with locally advanced and metastatic urothelial cancer receiving anti-PDL1 therapy. Consensus guidelines for antibiotic use in these patients, as well as diagnostic tools and corrective measures, are needed to decrease primary resistance to immune checkpoint inhibitors.

Personalized decision-making is the ultimate goal of managing men with lower urinary tract symptoms caused by benign prostatic obstruction. Urodynamics can provide valuable information in these patients and a recent multicentre randomized trial has highlighted important findings warranting consideration, as well as indicating that further insights are needed.

A new study describes the effects of androgen status on the different cell types in mouse and human prostates, illustrating the potential of single-cell RNA sequencing to study specific biological processes in unprecedented detail. Translating these new insights into clinical use will increase precision and personalization of prostate cancer treatment.

Anti-PD1 and anti-PDL1 immunotherapy has transformed urothelial carcinoma treatment. Pembrolizumab is the only immunotherapy agent shown to have survival benefit compared with standard chemotherapy after progression on platinum-containing chemotherapy. Initial National Institute for Health and Care Excellence (NICE) approval was based on efficacy data, but the final appraisal report rejected use of pembrolizumab owing to treatment cost.

Bladder cancer outcomes differ between men and women. Elucidating this sexual dimorphism, genomic analyses found differing molecular subtype distributions and androgen response activities in muscle-invasive bladder cancer in men and women. Together with knowledge of cancer driver genes, biomarkers and clinical characteristics, these findings will hopefully lead to sex-based personalized research and management of bladder cancer.

Electronic cigarette (e-cigarette) use has risen rapidly over the past decade, despite limited knowledge of the risk of carcinogenesis and broader health implications. A recent systematic review summarizes the current evidence on carcinogen biomarkers in the urine of e-cigarette users. The findings warrant consideration and indicate that further insights are urgently needed.

Extirpative surgery for all patients with upper tract urothelial carcinoma (UTUC) risks overtreatment and associated morbidity. Endoscopic approaches are particularly applicable for low-risk disease albeit with the potential for ipsilateral upper tract recurrence. Adjuvant and ablative intracavitary therapies are current and future strategies that could improve disease outcomes and increase adoption of kidney preservation for UTUC.

A subgroup analysis of the RTOG 9601 trial, which stratified participants according to their pretreatment serum PSA levels, suggests disparate responses to therapy and potentially concerning cardiac and neurological effects in some men. However, subgroup analyses are notoriously difficult to interpret and the data should be considered with caution before changes are made to clinical practice.

A pilot trial of low-carbohydrate diet after definitive treatment for localized prostate cancer stopped early owing to futility but provides intriguing results in secondary analyses. The study offers an important opportunity to highlight caveats in data interpretation and to consider requirements for successful future research on dietary interventions in men with prostate cancer.

A new trial evaluated whether neoadjuvant use of the tumour vaccine GVAX plus cyclophosphamide with androgen deprivation therapy (ADT) would augment antitumour immunity. ADT alone led to increased CD8⁺ T cell infiltration but also increases in regulatory cell populations. The results suggest that ADT should be used with treatments targeting the recruitment and persistence of these regulatory populations.

A new study reports the 5-year patient-reported outcome data from a population-based cohort of men with localized prostate cancer. These findings in conjunction with data on survival, treatment burden and treatment cost can assist clinicians in explaining to newly diagnosed patients the likely effects of modern management options on quality of life.

A randomized controlled trial has shown no statistically significant effect of low-intensity shockwave therapy when added to standard postprostatectomy pharmaceutical penile rehabilitation. Although this trial had a number of limitations, it adds to a body of literature that shows little effect of this therapy and emphasizes the need for development of effective therapeutic options for these patients.