AUA 2019: Androgen Deprivation Therapy is Associated with Urethral Atrophy and Cuff Erosion
To test their hypothesis that patients receiving ADT for advanced prostate cancer are at increased risk for urethral atrophy and AUS complications, the authors did a retrospective review of their institutions AUS database. These cases were performed by a single surgeon between 2007-2018. Patients were divided into two categories, those who had received ADT (often combined with radiation treatment), and those who had not received ADT or radiation, and had normal serum testosterone, which was defined as. During data collection and analysis they used a cuff size of 3.5cm as a means to identify if urethral atrophy was appreciated.
In this database for this period of time, there were 643 patients, of which 67 were identified as having been on ADT, with an additional 32 with no history of ADT or radiation with known normal testosterone. In the ADT group, 17/67 (26.2%) went on to develop urethral cuff erosion as compared to 1/32 (7%) in the normal testosterone (NT) group. This was deemed to be statistically significant (p=0.02). The rates of using 3.5cm cuff was also higher in the ADT group 32/67 (48.5%) as compared to the NT group 9/32 (28.1%). Amongst the patients who received a 3.5cm cuff in these sub-groups, there was also a higher rate of urethral erosion with the patients who received ADT 10/32 (31.2%) as compared to the NT group 1/9 (11.1%).
With this data, the authors support their hypothesis that there is a correlation between ADT and both urethral atrophy (as implied in the higher rates of using a 3.5cm cuff), and urethral cuff erosion. As the authors acknowledge the utility of this information is primarily for patient counseling prior to surgical intervention, to confirm that certain patients understand that they might be at increased risk for diminishing response, or other surgical complications such as cuff erosion which would require surgical repair. In the detailed review and discussion, the authors reported 16 of the 67 patients on ADT did not receive radiation pelvic radiation. When they presented their univariate and multivariate analysis data it showed that on univariate analysis both ADT and previous pelvic radiation were significant risk factors for urethral cuff erosion, however on multivariate analysis pelvic radiation remained a significant risk factor for urethral cuff erosion, whereas ADT did not (p<0.0001 vs p=0.1), which supports it may not be the ADT but the pelvic radiation that more significantly increases the risk of cuff erosion. Follow up questions from what this study may indicate, which may further test this hypothesis, is if patients even without a history of ADT should routinely have their testosterone levels checked prior to AUS implantation, and if there would be a significant decrease in risk of AUS cuff erosion if this were then corrected with testosterone supplementation preoperatively.
Presented by: Michael Davenport, MD, University of Texas, Southwestern Medical Center, Dallas, Texas
Written by: Ross Moskowitz, MD; Assistant Clinical Professor of Urology, University of California Irvine Medical Center; @rossmosk1 at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois