ADVANCES IN UROLOGICAL DIAGNOSIS AND IMAGING
A dvA nces in U rologic A l d i Agnosis A nd i
EDITOR in CHIEF
Pietro Cazzola (Pathologyst), Milan (Italy)
CO-EDITORS
Donatella Tedeschi (Pathologyst), Milan (Italy)
Konstantinos Stamatiou (Urologist), Piraeus (Greece)
EDITORIAL BOARD
Ahmed Hashim, London (Great Britain)
Ali Tamer, Cairo (Egypt)
Benatta Mahmoud, Oran (Algeria)
Bhatti Kamran Hassan, Alkhor (Qatar)
Cheng Liang, Indianapolis (USA)
Fragkiadis Evangelos, Athens (Greece)
Gül Abdullah, Bursa (Turkey)
Jaffry Syed, Galway (Ireland)
Kastner Christof, Cambridge (Great Britain)
Lopez-Beltran Antonio, Lisbon (Portugal)
Salomon George, Hamburg (Germany)
Waltz Joachen, Marseille (France)
Wijkstra Hessel, Eindhoven (Netherlands)
General Information
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Contents
2. ORIGINAL ARTICLE
Twin tumour of the bladder with unusual pathology posing a diagnostic dilemma
Konstantinos Stamatiou, Konstantinos Tzelepis
7. TRAINING IN UROLOGY
Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024)
10. URONEWS
Prostate and cancer pesticides
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Twin tumour of the bladder with unusual pathology posing a diagnostic dilemma
Konstantinos Stamatiou1, Konstantinos Tzelepis2
1Department of Urology, Tzaneio General Hospital, Piraeus, Greece
2Department of Urology, General Hospital of Nikaia, Athens, Greece
Introduction and Aim:
SUMMARY
Adenocarcinomas are malignant neoplasms of epithelial tissue that have glandular origin, glandular characteristics, or both. Primary adenocarcinomas rarely occur in the urinary bladder and are usually diagnosed at an advanced stage. Adenocarcinoma of the urachus (AU) is a rare malignant tumor developing insidiously in the bladder’s lumen. It shares similar histologic features with bladder adenocarcinoma (BA) but has a more favorable prognosis than BA. Treatment options for AU and BA differ given the natural history of each of these entities. This case report aims to present a diagnostic dilemma posed by a twin tumor of the anterior bladder wall with unusual pathology.
Presentation of case: A 50-year-old patient was presented to the outpatient department reporting hematuria. Abdominal ultrasound revealed a mass at the expense of the upper/anterior bladder wall while no lesion was noted outside of the bladder roof on the CT scan. The cystoscopy visualized a twin tumor arising mainly from the superior wall with an unusual appearance. An extended transurethral resection of the tumor
introdUction
The urachus is a a fibromuscular canal that connects the bladder to the allantois in the embryonic development. Αfter the third trimester as the canal closes it reduces to a fibromuscular film (median umbilical ligament) that connects the umbilicus with the dome of the urinary bladder. Urachal remnant may persist in a significant number of adults (approximately 32%) (1) having the form of a tubular or ovular cystic structure lined by epithelium, surrounded by connective tissue and musculature. In a very small part of them urachus carcinoma may arise from urachal remnants. This malignancy accounts for <1% of all bladder cancers (2). Ninety percent of urachus carcinomas are adenocarcinomas, that develop from intestinal metaplasia of the epithelial component while the remaining are mainly non-glandular neoplasms (urothelial, squamous cells,
was performed. The histology revealed adenocarcinoma with poorly differentiated areas showing solid rudimentary tubular architecture and areas with focal mucinous differentiation. The tumor extended invasively to parts of the muscular layer. A thoracic CT scan and colonoscopy revealed no obvious sites of distant metastases or primary disease of the bowel. Despite no evidence of urachal remnants on the pelvis MRI, a diagnostic dilemma was posed between a diagnosis of adenocarcinoma of urachus and mixed type poorly differentiated adenocarcinoma of the bladder.
Conclusion: It is actually difficult to differentiate AU from BA because of the overlapping histologic and immunohistochemical features. Currently, the distinction between these two entities is mainly based on topographic criteria that in some cases are confounding. Since a discrepancy between AU from BA diagnosis may influence treatment decision and treatment outcome, more strict criteria for the distinction between these two entities are needed.
Key words: Bladder cancer; Hematuria; Urachal adenocarcinoma; Urinary mucosal secretion.
neuroendocrine and mixed type) (3). It is most common in men in the fifth and sixth decades.
The primary adenocarcinoma of the bladder originates from the urothelium however exhibit a pure glandular phenotype. It is also an unusual malignancy (accounting for less than 2% of bladder tumors) found mainly in men in the sixth and seventh decades. It usually arises from the trigone and posterior wall but can be found anywhere in the bladder (4).
The most common symptoms of both adenocarcinoma of the urachus (AU) and primary bladder adenocarcinoma (BA), are hematuria irritative symptoms and mucusuria. AU and BA have similar macroscopic appearance and share similar histologic features. These tumors tend to present at an advanced stage and exhibit aggressive behaviour though AU has a more favourable prognosis than BA (5). Treatment options for AU and BA differs given
the natural history of each of these entities. The aim of this case report is to present a diagnostic dilemma posed by a twin tumour of the anterior bladder wall with unusual pathology.
PresentAtion of cAse
A 50-year-old patient with no prior history of hematuria was presented to the outpatient department reporting an episode of intermittent urinary mucosal secretion aggravated by the appearance of macroscopic hematuria. Abdominal ultrasound revealed a mass at the expense of the anterior wall of the bladder (Figures 1a and 1b). Computed tomography showed calcifications of the bladder dome while no lesion was noted outside of the bladder wall. The cystoscopy visualized a twin tumor arising mainly from the superior wall with unusual appearance. The left tumor was yellowish and had gross mucinous multinodular appearance while the right was whitish and had a solid configuration, partially covered by urothelium with reactive changes (Figure 2a). An extended transurethral resection of the tumor was performed (Figure 2b). The histology revealed adenocarcinoma with poorly differentiated areas showing solid rudimentary tubular architecture and areas with focal mucinous differentiation characterized by local mucus production with signet ring cells floating in mucinous lakes. Focal areas of normal urothelium and nests of Von Brunn were also present (Figure 3b). The above tumor extended invasively to parts of the muscular layer of the bladder wall. The immunostains revealed cytokeratin 20 (CK20), CK7 and CDX2 expression, CEA, EMA, P53, Ki67CD15/LeuM1 expression and absence of expression for Cata 3, CK903, chromogranin A, synaptophysin, NKX3-1, Ca125, p63, B catenin. According to the pathologist, histological study revealed a rather unusual AU. A thoracic CT scan and a virtual colonoscopy were performed showing no obvious sites of distant metastases, or primary disease of the bowel. MRI of the pelvis showed no evidence of urachal remnant. The patient asked for a
second advice. Following reevaluation of the specimens, a diagnosis of a mixed type poorly differentiated AB was suggested.
2.
A. Cystoscopy: A twin tumor arising from the anterior bladder wall.
B. Gelatinous appearance of the tumour’s cut surface apparently due to abundant mucin production.
Figures 1A and 1B. Ultrasound: A large mass protruding in the lumen of the bladder.
Figure
discUssion
UA usually presents as a solitary discrete polypoid mass in the dome of the bladder, although it may be seen anywhere along the anterior midline of the bladder wall. The bladder mucosal surface may be intact or ulcerated (5). The cut surface often has a glistening appearance due to production of abundant mucin. It is a rare entity and for this reason, the relative literature is scarce. Because of its rarity, there is no consensus between experts about the nomenclature, the diagnostic criteria, the staging system to use, and the best therapeutic options (6). The most recent diagnostic criteria published in the 2016 World Health Organization (WHO) manual for the diagnosis of urachal adenocarcinoma are as follows: (a) location of the tumor in the bladder dome and/or anterior wall, (b) epicenter of carcinoma in the bladder wall,
Figure 3 A. Immunostains: (a) CDX2 positive staining in the tumor, B. CEA positive staining in the tumor.
Figure 4. Immunostains:
A. CK7 positive staining in the tumor, B. CK20 positive staining.
Figure 5. Immunostains:
A. CK903, B. EMA.
(c) absence of widespread cystitis cystica and/or cystitis glandularis beyond the dome and anterior wall, and (d) absence of a known primary tumor elsewhere (7). These criteria suggested by Johnson et al. have been widely adopted, however in some cases are confounding and inadequate. As mentioned above AU and BA have similar macroscopic appearance and share similar histologic features. In fact, the generally accepted histological subtyping of AU is similar to that of conventional BA (enteric, mucinous, signet ring cell, mixed type or not otherwise specified). However, most of the BA are of enteric type while most of AU are of mucinous type. A small number of them may be of mixed type. Mucinoustype BA and mixed enteric/mucinous type BA produce abundant extracellular mucin, forming pools of mucin with floating tumor cells a phenomenon that is common in AU (8). The twin tumor presented here fulfilled almost all the aforementioned WHO criteria: it was mainly originated from the superior wall, there was absence of widespread
cystitis cystica and/or cystitis glandularis beyond the dome and anterior wall, and no primary tumor elsewhere was found. On the other hand, the epicenter of carcinoma was not in the bladder wall and no presence of urachal remnant was detected. According to some experts, this feature is helpful for the diagnosis of AU but its absence does not preclude the urachal origin (8). Similarly, the absence of cystitis cystica and/or cystitis glandularis proximal to the tumor, does not preclude the diagnosis of BA since this phenomenon also occurs in primary BA. In fact, some authors reported that in most primary BA, adjacent normal mucosa is usually normal and in only 23% of them cystitis cystica and/or cystitis glandularis may be present (8). Absence of a known primary tumor elsewhere is a common characteristic of both primary BA and AU.
Immunohistochemically, the adenocarcinoma of the present case, expressed CK20, CK7 and CDX2 stains. According to the literature the majority (>90%) of primary bladder adenocarcinomas are CDX-2 positive. Positive staining for
Figures 6a,6b.
Immunostains:
A. Gata 3(-) positively expressed in the superficial urotheliun,
B. H-Ex4 positive staining of the tumor.
Figures 7
Immunostains:
A. H-Ex10, positive staining,
B. P53 negative staining.
Figures 8
Immunostains:
A. Η-Εχ10 signet ring cells floating in mucinous lakes,
B. Η-Εχ40 positive staining.
CK7 is rather usual in primary (�60%) than in secondary bladder adenocarcinomas9. Positive staining for CK20 and CEA is more usual (>80%) for primary bladder adenocarcinomas than for urachal adenocarcinomas (�60%). However, the urachal adenocarcinoma is generally positive for and CDX2, CK7 in 60% of the cases, and 34βE12 in 66% but only very focally. GATA3 and p63 expression is seen in almost 90% of urothelial carcinomas but never in bladder and urachal adenocarcinomas (8,10). The differential diagnosis of AU, is between primary BA or metastatic tumor. For the exclusion of vesical origin, the fulfillment of diagnostic criteria must be taken into account. For the exclusion of the metastatic origin, thorough exploration and the results of immunostains are very important11. In this particular case the absence of urachal remnant wouldn’t allow for an accurate staging according to the universally accepted Sheldon staging system for urachal carcinomas (stage I: AU Confined to urachal mucosa Confined to urachus and/or bladder, stage II: Invasion
confined to urachus itself, stage III: Extending beyond the muscular layer of urachus to bladder and/or abdominal wall. Stage IV: Metastatic AU to lymph nodes and/or to distant sites) (11).
On the other hand, the adoption of the criteria of Wheeler et al. for AU diagnosis (tumors located in the bladder dome, absence of cystitis cystica et glandularis, invasion of muscle or deeper structures, presence of the urachal remnant, sharp demarcation between the tumor and surface epithelium, presence of the suprapubic mass, and tumor growth in the bladder wall that extends into the space of Retzius) (11) favored a final diagnosis of BA.
While diagnosis of AU could justify a partial cystectomy with en-bloc resection of the urachal ligament with the bladder dome, the final diagnosis of BA required radical cystectomy to appropriately control the tumor. Of note, there is yet no proven role for neoadjuvant or adjuvant chemotherapy.
conclU sion
It is difficult to differentiate AU from BA because of the overlapping histologic and immunohistochemical features. Currently, the distinction between these two entities is mainly based on topographic criteria that in some cases are confounding. Since a discrepancy between AU from BA diagnosis may influence treatment decision and treatment outcome, more strict criteria for the distinction between these two entities are needed.
references
1. Wilson AL, Gandhi J, Seyam O, Rahmani B, Patel S, Joshi G, et al. Urachal anomalies: A review of pathological conditions, diagnosis, and management. Translational Research in Anatomy 2019;16:100041
2.Yu JS, Kim KW, Lee HJ, Lee YJ,Yoon CS, Kim MJ. Urachal remnant diseases: spectrum of CT and US findings. Radiographics. 2001;21(2):451-61.
3. Ashley RA, Inman BA, Sebo TJ, Leibovich BC, Blute ML, Kwon ED, Zincke H. Urachal carcinoma: clinicopathologic features and long-term outcomes of an aggressive malignancy. Cancer 2006;107(4):712-20.
4. Eissa SS, Block N, Khaled HM, Shoman SH, Nassiri M, Nadji M. Primary enteric-type adenocarcinomas of the urinary bladder are histogenetically analogous to colorectal carcinomas: Immunohistochemical evaluation of 109 cases. Journal of Advanced Research 2010;1(2):151-156,
5. Pinthus JH, Haddad R, Trachtenberg J, Holowaty E, Bowler J, Herzenberg AM, et al. Population based survival data on urachal tumors. J Urol. 2006;175(6):2042-7.
6. Sampaio R., Garcia J. P., Peixoto C. Urachal tumour: case report of an uncommon neoplasm. Virchows Archiv. 2013;463(supplement 1):101–352.
7. Moch H., Humphrey P. A., Ulbright T. M., Reuter V. The 2016 WHO Classification of Tumours of the Urinary System and Male Genital Organs-Part B: Prostate and Bladder Tumours. Eur Urol. 2016;70(1):106-119.
8. Eissa SS, Block N, Khaled HM, Shoman SH, Nassiri M, Nadji M. Primary enteric-type adenocarcinomas of the urinary bladder are histogenetically analogous to colorectal carcinomas: Immunohistochemical evaluation of 109 cases. Journal of Advanced Research 2010;1(2):151-156,
9. Bao B, Hatem M, Wong JK. Urachal adenocarcinoma: a rare case report. Radiol Case Rep. 2016;12(1):65-69
10. Dadhania V, Czerniak B, Guo CC. Adenocarcinoma of the urinary bladder. Am J Clin Exp Urol 2015;3(2):51-63
11. Paner G. P., Lopez-Beltran A., Sirohi D., Amin M. B. Updates in the pathologic diagnosis and classification of epithelial neoplasms of urachal origin. Advances in Anatomic Pathology 2016;23(2):71–83.
C orresponden C e Konstantinos Stamatiou, MD 2 Salepoula str., 18536 Piraeus, Greece E-mail: stamatiouk@gmail.com
Updates to Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2024)
This AUA guideline is provided free of use to the general public for academic and research purposes. Benjamin N Breyer, Sennett K Kim, Erin Kirkby, Alexis Marianes , Alex J Vanni, O Lenaine Westney. J Urol. 2024 Oct;212(4):531-538. doi: 10.1097/JU.0000000000004088. Epub 2024 Jun 27.
This is a brief summary to help younger colleagues.
In 2023 the American Urological Association (AUA) requested an Update Literature Review (ULR) to incorporate new evidence generated since the 2019 publication of this Guideline. The resulting 2024 Guideline Amendment addresses updated recommendations to provide guidance for the care of patients with incontinence after prostate treatment (IPT).
gUideline stAtements
Pre-Treatment
1. Clinicians should inform patients undergoing localized prostate cancer treatment of all known factors that could affect continence. (Moderate Recommendation; Evidence Level: Grade B)
2. Clinicians should counsel patients regarding the risk of sexual arousal incontinence and climacturia following localized prostate cancer treatment. (Strong Recommendation; Evidence Level: Grade B)
3. Clinicians should inform patients undergoing radical prostatectomy that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment. (Strong Recommendation; Evidence Level: Grade A)
4. Prior to radical prostatectomy, clinicians may offer patients pelvic floor muscle exercises or pelvic floor muscle training. (Conditional Recommendation; Evidence Level: Grade C)
5. Clinicians should inform patients undergoing radical prostatectomy or transurethral resection of the prostate after radiation therapy of the high rate of urinary incontinence following these procedures. (Moderate Recommendation; Evidence Level: Grade C)
Post-Prostate Treatment
6. In patients who have undergone radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training in the immediate post-operative period. (Moderate Recommendation; Evidence Level: Grade B)
7. In patients with bothersome stress urinary incontinence after prostate treatment, clinicians may offer surgery as early as six months if incontinence is not improving despite conservative therapy. (Conditional Recommendation; Evidence Level: Grade C )
8. In patients with bothersome stress urinary incontinence after prostate treatment despite conservative therapy, clinicians should offer surgical treatment at one year post-prostate treatment. (Strong Recommendation; Evidence Level: Grade B)
Evaluation of Incontinence after Prostate Treatment
9. Clinicians should evaluate patients with incontinence after prostate treatment with history, physical exam, and appropriate diagnostic modalities to categorize type and severity of incontinence and degree of bother. (Clinical Principle)
10. In patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence, clinicians should offer treatment options per the American Urological Association Overactive Bladder Guideline. (Clinical Principle)
11. Prior to surgical intervention for stress urinary incontinence, clinicians should confirm stress urinary incontinence by history, physical exam, or ancillary testing. (Clinical Principle)
12. Clinicians should inform patients with incontinence after prostate treatment of management options for their incontinence, including surgical and non-surgical options. (Clinical Principle)
13. In patients with incontinence after prostate treatment, clinicians should discuss risk, benefits, and expectations of different treatments using the shared decisionmaking model. (Clinical Principle)
14. Prior to surgical intervention for stress urinary incontinence, clinicians should perform cystourethroscopy to assess for urethral and bladder pathology that may affect outcomes of surgery. (Expert Opinion)
15. Clinicians may perform urodynamic testing in patients prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling. (Conditional Recommendation; Evidence Level: Grade C)
Treatment Options
16. In patients seeking treatment for incontinence after radical prostatectomy, clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training. (Moderate Recommendation; Evidence Level: Grade B)
17. Clinicians should discuss the option of artificial urinary sphincter with patients who are experiencing mild to severe stress urinary incontinence after prostate treatment. (Strong Recommendation; Evidence Level: Grade B)
18. Prior to implantation of artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device. (Clinical Principle)
19. In patients who select artificial urinary sphincter, clinicians should preferentially utilize a single cuff perineal approach. (Moderate Recommendation; Evidence Level: Grade C)
20. Clinicians should discuss the option of male slings with patients as treatment options for mild to moderate stress urinary incontinence after prostate treatment. (Moderate Recommendation; Evidence Level: Grade B)
21. Clinicians should not routinely implant male slings in patients with severe stress incontinence. (Moderate Recommendation; Evidence Level: Grade C)
22. Clinicians may offer adjustable balloon devices to non-radiated patients with mild to severe stress urinary incontinence after prostate treatment. (Conditional Recommendation; Evidence Level: Grade C)
23. Clinicians should manage patients with stress urinary incontinence after treatment of benign prostatic hyperplasia the same as patients that have undergone radical prostatectomy. (Moderate Recommendation; Evidence Level: Grade C)
24. In patients with stress urinary incontinence after primary, adjuvant, or salvage radiotherapy who are seeking surgical management, clinicians should offer artificial urinary sphincter over male slings or adjustable balloons. (Moderate Recommendation; Evidence Level: Grade C)
25. In patients with incontinence after prostate treatment, clinicians should counsel patients that efficacy is low and cure is rare with urethral bulking agents. (Strong Recommendation; Evidence Level: Grade B)
26. Clinicians should consider other potential treatments for incontinence after prostate treatment as investigational, and patients should be counseled accordingly. (Expert Opinion)
Complications after surgery
27. Clinicians may counsel patients regarding risk factors for artificial urinary sphincter erosion. (Conditional Recommendation; Evidence Level: Grade C)
28. Clinicians should counsel patients that artificial urinary sphincter will likely lose effectiveness over time, and reoperations are common. (Strong Recommendation; Evidence Level: Grade B)
29. In patients with persistent or recurrent urinary incontinence after artificial urinary sphincter or sling, clinicians should again perform history, physical examination, and/or other investigations to determine the cause of incontinence. (Clinical Principle)
30. In patients with persistent or recurrent stress urinary incontinence after sling, clinicians should recommend an artificial urinary sphincter. (Moderate Recommendation; Evidence Level: Grade C)
31. In patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter, clinicians should discuss artificial urinary sphincter revision with the patient. (Strong Recommendation; Evidence Level: Grade B)
32. In patients presenting with infection or erosion of an artificial urinary sphincter or sling, clinicians should perform explantation and reimplantation should be delayed. (Clinical Principle)
• Very confident that the true effect lies close to that of the estimate of the effect B Moderate
• Moderately confident in the effect estimate
33. After explanting an eroded device, clinicians may manage artificial urinary sphincter urethral cuff erosion intra-operatively with urethral catheter alone, in situ urethroplasty, or anastomotic urethroplasty. (Expert Opinion)
Special situations
34. Clinicians should discuss urinary diversion with patients who are unable to obtain long-term quality of life due to incontinence after prostate treatment. (Expert Opinion)
35. In patients with bothersome incontinence during sexual activity, clinicians should offer treatment. (Moderate Recommendation; Evidence Level: Grade C)
• Confidence in the effect estimate is limited
• The true effect may be substantially different from the estimate of the effect
• The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different C Low Very Low
• Very little confidence in the effect estimate
• The true effect is likely to be substantially different from the estimate of effect
36. In patients with stress urinary incontinence following urethral reconstructive surgery, clinicians may offer artificial urinary sphincter and counsel that complication rates are higher. (Conditional Recommendation; Evidence Level: Grade C)
37. In patients with incontinence after prostate treatment and erectile dysfunction, clinicians may offer a concomitant or staged procedure. (Conditional Recommendation; Evidence Level: Grade C)
38. In patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture, clinicians should treat the patient prior to surgery for incontinence after prostate treatment. (Clinical Principle).
Table 1: Strength of Evidence Definitions.
Prostate and cancer pesticides
A recent article in Cancer ( Pesticides and prostate cancer incidence and mortality: An environment-wide association study. Soerensen SJC, Lim DS, Montez-Rath ME, Chertow GM, Chung BI, Rehkopf DH, Leppert JT. Cancer. 2024 Nov 4.doi: 10.1002/cncr.35572. Online ahead of print. ) highlighted the possible link between certain pesticides and increased prostate cancer incidence and mortality.
BAckgroUnd
Prostate cancer is the most common cancer among men in the United States, yet modifiable risk factors remain elusive. In this study, the authors investigated the potential role of agricultural pesticide exposure in prostate cancer incidence and mortality.
methods
For this environment-wide association study (EWAS), linear regression was used to analyze county-level associations between the annual use of 295 distinct pesticides (measured in kg per county) and prostate cancer incidence and mortality rates in the contiguous United States. Data were analyzed in two cohorts: 1997-2001 pesticide use with 2011-2015 outcomes (discovery) and 2002-2006 use with 2016-2020 outcomes (replication). The reported effect sizes highlight how a 1-standard-deviation increase in log-transformed pesticide use (kg per county) corresponds to changes in incidence. Analyses were adjusted for county-level demographics, agricultural data, and multiple testing.
resUlts
Twenty-two pesticides showed consistent, direct associations with prostate cancer incidence across both cohorts. Of these, four pesticides were also associated with prostate cancer mortality. In the replication cohort, each 1-standard-deviation increase in log-transformed pesticide use corresponded to incidence increases per 100,000 individuals (trifluralin, 6.56 [95% confidence interval (CI), 5.04-8.07]; cloransulam-methyl, 6.18 [95% CI, 4.06-8.31]; diflufenzopyr, 3.20 [95% CI, 1.09-5.31]; and thiamethoxam, 2.82 [95% CI, 1.14-4.50]). Limitations included ecological study design, potential unmeasured confounding, and lack of individual-level exposure data.
conclUsions
The results of this study suggest a potential link between certain pesticides and increased prostate cancer incidence and mortality. These findings warrant further investigation of these specific pesticides to confirm their role in prostate cancer risk and to develop potential public health interventions.
