Adapting to the long pandemic

Our first issue was March 2020, right at the beginning of the Covid‐19 pandemic, and here we are 2 years later still going. As I was looking for photography ideas for this issue, I noted that many pictures available are sort of ‘pandemic‐related’ events, as we have all had to make significant adjustments in our lifestyles, workflows and personal time. Many of us in academic medicine were frequent jetsetters, moving around the globe to various workshops and meetings and often enjoying a high loyalty status from various travel service companies. Now, I have had to adapt to a more ‘road’ based form of travel and being cautious with large crowds. Some of my colleagues have bought Pelotons® and/or taken up road biking, rather than going to the gym. I'm sure we have all made some sort of adjustment to how we work remotely or pursue our free time activities. For my family, here are four of our related ‘pandemic’ strategies for how to adjust: exploring our regional events more (Figure 1); jumping into recreational vehicle travel (Figure 2); pet adoption (Figure 3); and cautious use of domestic trips with air travel (Figure 4). How have you adjusted to the pandemic era?

FIGURE 1.

Pandemic Strategy #1: ‘Local’ travel is now the norm. These are scenes from the annual Texas Renaissance Fair, a 4‐week event near Houston, which features food, shopping, medieval themes/costumes and several medieval‐themed performances. Left panel: The Fire Whip Show, a demonstration of mastery of the whip and knife throwing; upper right panel: the Birds of Prey Show; lower right panel: the jousting contest

FIGURE 2.

Pandemic Strategy #2: Travel with wheels. The United States has seen a massive growth in the recreational vehicle industry. I had been eyeing an airstream for many years, and the pandemic made us pull the trigger on this 27‐ft international model with the rear hatch option. It has been a great way to explore Texas, and we have plans to explore other regions as well. It can be useful for virtual work also. In the upper left panel, you see a typical Zoom shot of a robotic course I gave to the virtual 2021 AUA meeting, connecting from my laptop in the back of the airstream with my colleagues Fatih Atug (Turkey), Kevin Zorn (Canada) and Koon Rha (South Korea)

FIGURE 3.

Pandemic Strategy #3: Furry friends. We have had our two dogs for a long time, Kara (7 years) and Sophie (17 years), but with our daughters in school in other cities and doing so much remote classwork, they have adopted their own furry friends to keep company while on Zoom, Winnie (left), a Tabby cat, and Lissa (right), a pure Bengal cat. The pandemic has been associated with a global increase in pet adoption

FIGURE 4.

Pandemic strategy #4: ‘Cautious’ regional travel. Scenes from a summer trip to Alaska. Air travel for personal trips is still feasible, but fewer and far between given the challenges with air travel, testing pre/post trip, and for a while, we had to quarantine upon return from out of state

For the March 2022 issue of BJUI Compass, we have 10 articles to share …

• To the Journals… In this issue, our review article by Iacob ¹ addresses the topic of male neonatal circumcision, focusing on complications when the procedure is performed for elective indications. The background sections outline the history of its performance for religious reasons or for health prevention. Their search focused on 78 articles that yielded 47 specific complications. Of course, many complications reported are isolated incidents or case reports, so not much opportunity for statistical statements. Their discussion/recommendations note the array of complications parents should be aware of when making a decision and that use of experienced providers with sterile settings can help.

• To the Clinic… The study by Grover et al. ² points out that low‐grade bladder cancer is the most common form of bladder cancer and has high rates of recurrences and operative interventions that drive significant healthcare costs, especially from repeat general anaesthetics. They report on an alternative approach to the standard TURBT in which 97 patients with advanced age and/or comorbid conditions were selected for an office‐based ablation with a laser. The cohort treatment was true monotherapy, that is, no enhanced vision or perioperative chemotherapy. Only 9.3% progressed to higher stage but non‐muscle invasive. Median progression free time was 5.7 years. Overall, 56% were treated for recurrence. The authors conclude that this alternative is safe/effective for low‐volume, low‐grade lesions in a well‐selected circumstance.

The multicentre study by Zorn et al. ³ is a highly useful procedure review in BPH surgery. Although numerous options exist for the routine case of LUTS/BPH selected for an intervention, the subcategory of managing very large prostates often reverts the options to a much smaller list that often requires significant training/skills such as HoLEP, simple open prostatectomy or robotic simple prostatectomy. Aquablation is an alternate technique. In this cohort study of glands with a median size of 107 g, the authors report 3‐year outcomes including metrics of improved IPSS, QOL, Q_max and PVR. A small sub‐cohort were successful at eliminating catheter use. Subsequent LUTS treatments required included 6% medications and 3% additional surgical treatment.

• To the Drawing Board… Ozaki et al. ⁴ performed an interesting ‘clinical trial to clinical practice’ study on metastatic urothelial cancer. With the growing evidence of immunotherapy playing a role in this population, they looked at a specific maintenance immunotherapy trial called JAVELIN Bladder 100. This trial created a set of eligibility criteria that included patients who did not progress on their first four cycles of platinum‐based chemotherapy and reported on the maintenance therapy efficacy. These authors then took these requirements and applied them to a broad population of patients presenting with the diagnosis; overall, only 38% were eligible for maintenance immunotherapy. The study has a number of useful observations on the challenges these patients face with chemotherapy resistance defining their overall metrics.

Another study in our academic section used this ‘trial eligibility’ concept to provide key insight on how clinical trial eligibility can describe patient cohorts and outcomes. In the study by Miura, ⁵ they looked at the localised/locally advanced muscle invasive bladder carcinoma and upper tract urothelial carcinoma groups that would meet eligibility for adjuvant immunotherapy based upon adverse pathologic features. Overall, a total of 52% of their cohorts met eligibility and were associated with significantly poor prognosis, especially driven by lymphovascular invasion and/or positive lymph nodes. Their study presents a useful risk model and several survival metrics from this large cohort.

Continuing with the advanced urothelial carcinoma theme, the paper by Okuyama et al. ⁶ focused on the specific concerns from immunotherapy trials that concomitant use of proton pump inhibitors for gastro‐oesophageal reflux and/or peptic ulcers or antibiotic use may have negative impacts on the known heterogeneous responses to immunotherapy. They carried out a retrospective, multicentre study of 160 patients with locally advanced or metastatic urothelial cancer treated with checkpoint inhibitors. For proton pump inhibitors, the objective responses rates were 20% versus 41% for non‐users. Multivariable analysis showed significant differences in progression free and overall survival for the proton pump use but not antibiotic use.

Switching to the field of functional urology, the paper by Konishi et al. ⁷ investigated the effect of advanced glycation end products (AGEs) on nocturia and sleep disorders. The key background information includes the known associations between sleep disturbances and nocturia and adds emerging information on oxidative stress imbalance as a relation to nocturia. With a method of measuring AGEs in the skin, the authors could measure and define a population and correlate to sleep and nocturia. Over a 5‐year study period, the baseline AGEs did not correlate with PSQI score or nocturia; however, with follow‐up, the PSQI score increased significantly in the AGEs' high group, but no change with nocturia.

The paper by Adib ⁸ is a research communication in metastatic urothelial carcinoma that focuses on biomarker‐informed choices in immunotherapy. The drug of interest is enfortumab vedotin, an anti‐Nectin‐4 antibody–drug conjugate that is approved for progression after platinum‐based chemotherapy. The biomarker was FGFR2/3 mutations, which may occur in 15%–20% of metastatic urothelial cancers. In this study, the mutations did not influence clinical outcomes such as objective responses rates, progression‐free survival or overall survival.

The study by Khoshkar ⁹ focuses on long‐term mortality rates in castrate‐resistant prostate cancer in the era before novel hormonal drug therapies. They created a risk model using PSA doubling times. The median survival time was 1.86 years, with faster PSA doubling times and overall PSA at the time of CRCP increasing the risk of death. The authors discuss how one might use this information to decide how aggressively to treat a patient at CRCP timing. The paper makes a deep dive into various risk variables and models that might differentiate prostate cancer‐related versus non‐related death.

• To the Future… For our innovation section, the paper from Ando et al. ¹⁰ takes up the challenge of trying to correlate surgical technique at robotic prostatectomy with urinary continence. They focused on video review evidence of preserved urethral length and found a correlation with longer length and continency recovery. The threshold of interest was 16 mm in length. Other predictors in a multivariable model included BMI and gland size.