HOW I DO IT

• How I Do It: Maintenance avelumab for advanced urothelial carcinoma

  Lalani A. Aly-Khan Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada

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  For more than four decades, platinum-based chemotherapy regimens have served as the established standard-of-care for advanced urothelial carcinoma (aUC). However, advancements in our understanding of cancer biology and tumor microenvironment have reshaped the therapeutic landscape and prognosis of this incurable disease. Immune checkpoint inhibitors (ICIs) that target programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) are firmly established tools in aUC management, leading to enhanced life span and improved quality of life for patients. In patients who achieved stable disease or better following platinum-based chemotherapy, maintenance therapy with the PD-L1 antibody avelumab significantly enhanced overall survival (OS) by approximately 7 months compared to best supportive care in the phase 3 JAVELIN Bladder 100 trial. As a result, avelumab received FDA approval in June 2020 as a maintenance therapy for aUC patients treated with first-line platinum-based chemotherapy. Therefore, aUC care plans should incorporate maintenance avelumab into standard first-line treatment regimens for these patients. The objective of this brief article is to provide insight into the utilization of avelumab, identify patients who may benefit from this treatment, and review the methodology, advantages, potential side effects and their management.

  Keywords: bladder cancer, avelumab, advanced urothelial carcinoma, metastatic, immune checkpoint inhibitor,

  Aug 2023 (Vol. 30, Issue 4 , Page 11633)
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• How I Do It: Ureteroscopy and high-power holmium laser lithotripsy to treat renal stones

  Higgins M. Andrew, Wolf J. Michael, Becker E. N. Russell, Ghani R. Khurshid Division of Endourology, Department of Urology, University of Michigan, Ann Arbor, Michigan, USA

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  In North America, ureteroscopy has become the most popular treatment modality for upper urinary tract urinary calculi. Herein we describe our technique for the treatment of renal stones with flexible ureteroscopy and high-power holmium laser lithotripsy. We discuss preoperative planning, intraoperative strategies, and laser settings for a high-frequency dusting technique with the goal to provide optimal patient outcomes.

  Keywords: ureteroscopy, urolithiasis, laser lithotripsy, dusting, fragmentation,

  Jun 2023 (Vol. 30, Issue 3 , Page 11574)
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• How I Do It: Optilume BPH catheter system

  Elterman S. Dean, Gao Bruce, Zorn C. Kevin, Bhojani Naeem, Te Alexis, Chughtai Bilal, Kaplan A. Steven Division of Urology, Department of Surgery, University of Toronto, Ontario, Canada

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  Benign prostatic hyperplasia (BPH) is a common and progressive disease affecting aging men which has a significant impact on quality of life. The Optilume BPH Catheter System (Optilume BPH) is a prostatic dilation system that combines balloon dilation with a localized transfer of paclitaxel to maintain long term patency. Optilume BPH can be deployed using standard rigid cystoscopy without general anesthesia in an office setting. Prospective data indicate that Optilume BPH has favorable functional and sexual patient outcomes. Readers will familiarize themselves with Optilume BPH, significant historical studies and the technique for deploying Optilume BPH.

  Keywords: prostate, BPH, MIST, Optilume,

  Jun 2023 (Vol. 30, Issue 3 , Page 11568)
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• Urethral bulking with native tissue during artificial urinary sphincter surgery          

  Rabinowitz J. Matthew, Liu L. James, Levy A. Jason, DuComb William, Burnett L. Arthur The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA  

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  The artificial urinary sphincter (AUS) is the “gold standard” surgical treatment for severe stress urinary incontinence.  However, a subset of patients with frail urethras may require technical adjuncts to ensure optimal cuff function.  Our objective is to provide a detailed tutorial of our institution’s method for performing urethral bulking with native tissue in patients with frail urethras during AUS surgery. We have found that urethral bulking with native tissue provides a cost-efficient and durable technique for improved AUS cuff coaptation.  Our experience demonstrates adequate short and intermediate term efficacy with limited complications.  These techniques equip surgeons with an alternative surgical approach for appropriate patients receiving AUS surgery who have been previously exposed to pelvic radiation and/or significant surgical morbidity resulting in frail urethral tissue.

  Keywords: prostate cancer, artificial urinary sphincter, urinary stress incontinence, urethral disease,

  Apr 2023 (Vol. 30, Issue 2 , Page 11516)
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• How I Do It: The prostatic urethral lift for obstructive median lobes

  Ashley S. Matt, Phillips Jason, Eure Gregg Summit Health, Bend, Oregon, USA

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  Millions of men in North America suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) are managed on medical therapy. Most patients, however, report poor adherence, and yet relatively few pursue more definitive surgical solutions. The Prostatic Urethral Lift (PUL) was designed to address many of the patient-identified barriers to surgery, namely iatrogenic sexual dysfunction, incontinence, lengthy recovery and postoperative catheterization. Randomized studies and large real world multicenter and database studies have demonstrated safety and effectiveness of PUL when addressing lateral lobe disease. In recent years further technique and device development has led to the FDA approval for PUL addressing obstructive median lobes as well. At 12 months, PUL median lobe patients in a controlled trial and a large retrospective study experienced average IPSS improvement of 13.5 and 11.6 points, QoL improvement of 3.0 and 2.1 points, and Qmax improvement of 6.4 and 7.1 mL/sec, respectively. In the controlled setting, both ejaculatory and erectile function were preserved and postoperative catheterization rates, while higher than lateral lobe PUL rates, were similarly short lived with a mean duration of 1.2 days. We describe the current technique for performing PUL to address the obstructive median lobe and detail a new device, which can make it easier to alleviate obstruction due to trilobar anatomy.

  Keywords: prostatic urethral lift, UroLift, benign prostatic hyperplasia, prostate, LUTS, BPH, PUL, middle lobe, median lobe,

  Apr 2023 (Vol. 30, Issue 2 , Page 11509)
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