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Publisher: John Wiley and Sons   (Total: 1602 journals)

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J. of Medical Primatology     Hybrid Journal   (Followers: 1, SJR: 0.473, h-index: 28)
J. of Medical Radiation Sciences     Open Access   (Followers: 2)
J. of Medical Virology     Hybrid Journal   (Followers: 6, SJR: 0.936, h-index: 82)
J. of Metamorphic Geology     Hybrid Journal   (Followers: 6, SJR: 2.003, h-index: 72)
J. of Microscopy     Hybrid Journal   (Followers: 2, SJR: 0.655, h-index: 70)
J. of Midwifery & Women's Health     Hybrid Journal   (Followers: 20, SJR: 0.439, h-index: 32)
J. of Molecular Recognition     Hybrid Journal   (SJR: 0.986, h-index: 56)
J. of Money, Credit and Banking     Hybrid Journal   (Followers: 17, SJR: 2.196, h-index: 55)
J. of Morphology     Hybrid Journal   (Followers: 3, SJR: 0.602, h-index: 44)
J. of Multi-Criteria Decision Analysis     Hybrid Journal   (Followers: 1)
J. of Multicultural Counseling and Development     Hybrid Journal   (Followers: 1, SJR: 0.314, h-index: 23)
J. of Muscle Foods     Hybrid Journal   (Followers: 2)
J. of Neurochemistry     Hybrid Journal   (SJR: 1.754, h-index: 162)
J. of Neuroendocrinology     Hybrid Journal   (Followers: 4, SJR: 1.038, h-index: 75)
J. of Neuroimaging     Hybrid Journal   (Followers: 1, SJR: 0.597, h-index: 39)
J. of Neuroscience Research     Hybrid Journal   (Followers: 6, SJR: 1.218, h-index: 113)
J. of Nursing and Healthcare of Chronic Illne Ss: An Intl. Interdisciplinary J.     Hybrid Journal   (Followers: 2)
J. of Nursing Management     Hybrid Journal   (Followers: 17, SJR: 1.028, h-index: 34)
J. of Nursing Scholarship     Hybrid Journal   (Followers: 2, SJR: 0.903, h-index: 45)
J. of Obstetric, Gynecologic, & Neonatal Nursing     Hybrid Journal   (Followers: 19, SJR: 0.499, h-index: 37)
J. of Obstetrics and Gynaecology Research     Hybrid Journal   (Followers: 13, SJR: 0.371, h-index: 30)
J. of Oral Pathology & Medicine     Hybrid Journal   (Followers: 2, SJR: 0.632, h-index: 51)
J. of Oral Rehabilitation     Hybrid Journal   (Followers: 2, SJR: 0.729, h-index: 51)
J. of Organizational Behavior     Hybrid Journal   (Followers: 18, SJR: 2.541, h-index: 83)
J. of Orthopaedic Research     Hybrid Journal   (Followers: 12, SJR: 1.246, h-index: 96)
J. of Paediatrics and Child Health     Hybrid Journal   (Followers: 15, SJR: 0.439, h-index: 46)
J. of Pathology     Hybrid Journal   (Followers: 7, SJR: 3.025, h-index: 122)
J. of Peptide Science     Hybrid Journal   (Followers: 14, SJR: 0.662, h-index: 42)
J. of Periodontal Research     Hybrid Journal   (SJR: 0.596, h-index: 53)
J. of Personality     Hybrid Journal   (Followers: 11, SJR: 1.803, h-index: 75)
J. of Petroleum Geology     Hybrid Journal   (Followers: 4, SJR: 0.471, h-index: 22)
J. of Pharmaceutical Sciences     Hybrid Journal   (Followers: 176, SJR: 1.206, h-index: 102)
J. of Philosophy of Education     Hybrid Journal   (Followers: 5, SJR: 0.491, h-index: 17)
J. of Phycology     Hybrid Journal   (Followers: 5, SJR: 0.864, h-index: 77)
J. of Physical Organic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.603, h-index: 45)
J. of Phytopathology     Hybrid Journal   (Followers: 2, SJR: 0.513, h-index: 33)
J. of Pineal Research     Hybrid Journal   (SJR: 1.435, h-index: 73)
J. of Plant Nutrition and Soil Science     Hybrid Journal   (Followers: 3, SJR: 0.732, h-index: 44)
J. of Policy Analysis and Management     Hybrid Journal   (Followers: 13, SJR: 1.297, h-index: 43)
J. of Policy and Practice In Intellectual Disabilities     Hybrid Journal   (Followers: 5, SJR: 0.684, h-index: 8)
J. of Political Philosophy     Hybrid Journal   (Followers: 29, SJR: 1.774, h-index: 26)
J. of Polymer Science Part A: Polymer Chemistry     Hybrid Journal   (Followers: 148, SJR: 1.281, h-index: 98)
J. of Polymer Science Part B: Polymer Physics     Hybrid Journal   (Followers: 22, SJR: 0.932, h-index: 87)
J. of Polymer Science Part C : Polymer Letters     Hybrid Journal   (Followers: 5)
J. of Popular Music Studies     Hybrid Journal   (Followers: 8, SJR: 0.142, h-index: 2)
J. of Product Innovation Management     Hybrid Journal   (Followers: 11, SJR: 2.157, h-index: 72)
J. of Prosthodontics     Hybrid Journal   (SJR: 0.358, h-index: 28)
J. of Psychiatric and Mental Health Nursing     Hybrid Journal   (Followers: 32, SJR: 0.473, h-index: 35)
J. of Psychological Issues in Organizational Culture     Hybrid Journal   (Followers: 1)
J. of Public Affairs     Hybrid Journal   (Followers: 2, SJR: 0.294, h-index: 5)
J. of Public Economic Theory     Hybrid Journal   (Followers: 4, SJR: 0.628, h-index: 8)
J. of Public Health Dentistry     Hybrid Journal   (Followers: 1, SJR: 0.546, h-index: 38)
J. of Quaternary Science     Hybrid Journal   (Followers: 23, SJR: 1.543, h-index: 59)
J. of Raman Spectroscopy     Hybrid Journal   (Followers: 9, SJR: 1.138, h-index: 62)
J. of Rapid Methods and Automation In Microbiology     Hybrid Journal   (Followers: 2)
J. of Regional Science     Hybrid Journal   (Followers: 6, SJR: 1.961, h-index: 36)
J. of Religious Ethics     Hybrid Journal   (Followers: 5, SJR: 0.189, h-index: 8)
J. of Religious History     Hybrid Journal   (Followers: 18, SJR: 0.133, h-index: 7)
J. of Renal Care     Hybrid Journal   (Followers: 1, SJR: 0.32, h-index: 11)
J. of Research In Reading     Hybrid Journal   (Followers: 10, SJR: 0.81, h-index: 19)
J. of Research in Science Teaching     Hybrid Journal   (Followers: 9, SJR: 2.998, h-index: 62)
J. of Research in Special Educational Needs     Hybrid Journal   (Followers: 3, SJR: 0.349, h-index: 8)
J. of Research on Adolescence     Hybrid Journal   (Followers: 4, SJR: 1.634, h-index: 47)
J. of Risk & Insurance     Hybrid Journal   (Followers: 8, SJR: 1.138, h-index: 32)
J. of School Health     Hybrid Journal   (Followers: 7, SJR: 0.79, h-index: 47)
J. of Sensory Studies     Hybrid Journal   (Followers: 2, SJR: 0.65, h-index: 27)
J. of Separation Science     Hybrid Journal   (Followers: 6, SJR: 1.092, h-index: 55)
J. of Sexual Medicine     Hybrid Journal   (Followers: 6, SJR: 1.006, h-index: 57)
J. of Sleep Research     Hybrid Journal   (Followers: 8, SJR: 1.05, h-index: 67)
J. of Small Animal Practice     Hybrid Journal   (Followers: 8, SJR: 0.737, h-index: 39)
J. of Small Business Management     Hybrid Journal   (Followers: 9, SJR: 0.988, h-index: 42)
J. of Social Issues     Hybrid Journal   (Followers: 16, SJR: 1.532, h-index: 63)
J. of Social Philosophy     Hybrid Journal   (Followers: 16, SJR: 0.118, h-index: 3)
J. of Sociolinguistics     Hybrid Journal   (Followers: 12, SJR: 1.511, h-index: 18)
J. of Software : Evolution and Process     Hybrid Journal   (Followers: 2)
J. of Supreme Court History     Hybrid Journal   (Followers: 6)
J. of Surgical Oncology     Hybrid Journal   (Followers: 1, SJR: 1.024, h-index: 69)
J. of Synthetic Lubrication     Hybrid Journal  
J. of Systematics Evolution     Open Access   (Followers: 4, SJR: 0.933, h-index: 19)
J. of Texture Studies     Hybrid Journal   (Followers: 2, SJR: 0.601, h-index: 29)
J. of the American Association of Nurse Practitioners     Partially Free   (Followers: 3, SJR: 0.36, h-index: 23)
J. of the American Ceramic Society     Hybrid Journal   (Followers: 20, SJR: 1.167, h-index: 119)
J. of the American Geriatrics Society     Hybrid Journal   (Followers: 12, SJR: 1.673, h-index: 138)
J. of the American Society for Information Science and Technology     Hybrid Journal   (Followers: 134, SJR: 1.555, h-index: 74)
J. of the American Water Resources Association     Hybrid Journal   (Followers: 18, SJR: 0.817, h-index: 56)
J. of the Association for Information Science and Technology     Hybrid Journal   (Followers: 1)
J. of the CardioMetabolic Syndrome     Hybrid Journal  
J. of the European Academy of Dermatology and Venereology     Hybrid Journal   (Followers: 9, SJR: 1.211, h-index: 51)
J. of the Experimental Analysis of Behavior     Hybrid Journal   (SJR: 0.535, h-index: 35)
J. of the History of the Behavioral Sciences     Hybrid Journal   (Followers: 1, SJR: 0.46, h-index: 13)
J. of the Institute of Brewing     Free   (SJR: 0.528, h-index: 25)
J. of the Peripheral Nervous System     Hybrid Journal   (Followers: 2, SJR: 0.935, h-index: 40)
J. of the Royal Anthropological Institute     Hybrid Journal   (Followers: 29, SJR: 1.128, h-index: 25)
J. of the Royal Statistical Society Series A (Statistics in Society)     Hybrid Journal   (Followers: 9, SJR: 1.258, h-index: 44)
J. of the Royal Statistical Society Series B (Statistical Methodology)     Hybrid Journal   (Followers: 19, SJR: 5.518, h-index: 75)
J. of the Royal Statistical Society Series C (Applied Statistics)     Hybrid Journal   (Followers: 13, SJR: 0.877, h-index: 47)
J. of the Science of Food and Agriculture     Hybrid Journal   (Followers: 20, SJR: 0.781, h-index: 80)
J. of the Society for Information Display     Hybrid Journal   (Followers: 1, SJR: 0.521, h-index: 30)
J. of the Society for the Anthropology of Europe     Hybrid Journal   (Followers: 8)
J. of the World Aquaculture Society     Hybrid Journal   (Followers: 13, SJR: 0.446, h-index: 36)

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Journal Cover BJU International
   [167 followers]  Follow    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
     ISSN (Print) 1464-4096 - ISSN (Online) 1464-410X
     Published by John Wiley and Sons Homepage  [1602 journals]   [SJR: 1.381]   [H-I: 96]
  • Extent of lymph node dissection at nephrectomy affects
           cancer‐specific survival and metastatic progression in specific
           sub‐categories of patients with renal cell carcinoma (RCC)
    • Authors: Umberto Capitanio; Nazareno Suardi, Rayan Matloob, Marco Roscigno, Firas Abdollah, Ettore Di Trapani, Marco Moschini, Andrea Gallina, Andrea Salonia, Alberto Briganti, Francesco Montorsi, Roberto Bertini
      Abstract: Objective To test whether the number of lymph nodes removed affects cancer‐specific survival (CSS) or metastatic progression‐free survival (MPFS) in different renal cell carcinoma (RCC) scenarios. Methods We used Cox regression analyses to analyse the effect of the number of lymph nodes removed on CSS and MPFS in 1983 patients with RCC treated with nephrectomy. To adjust for possible clinical and surgical selection bias, analyses were further adjusted for number of positive nodes, presence of metastases, age, performance status, T stage, tumour size and grade. Results The prevalence of lymph node invasion was 6.1%. The mean follow‐up period was 83.3 months. Multivariable analyses showed that the number of nodes removed had an independent, protective effect on CSS in patients with pT2a–pT2b or pT3c–pT4 RCC (hazard ratio [HR] 0.91, P = 0.008 and HR 0.89, P < 0.001, respectively), in patients with bulky tumours (tumour size >10 cm, HR 0.97, P = 0.03) or when sarcomatoid features were found (HR 0.81, P = 0.006). The removal of each additional lymph node was associated with a 3–19% increase in CSS. When considering MPFS as an endpoint, the number of nodes removed had an independent, protective effect in the same patient categories. Conclusions When clinically indicated, the number of nodes removed affects CSS and MPFS in specific sub‐categories of patients with RCC.
      PubDate: 2014-05-22T03:43:07.745286-05:
      DOI: 10.1111/bju.12508
       
  • The changing face of urinary continence surgery in England: a perspective
           from the Hospital Episode Statistics database
    • Authors: John Withington; Sadaf Hirji, Arun Sahai
      Abstract: Objective To quantify changes in surgical practice in the treatment of stress urinary incontinence (SUI), urge urinary incontinence (UUI) and post‐prostatectomy stress incontinence (PPI) in England, using the Hospital Episode Statistics (HES) database. Patients and Methods We used public domain information from the HES database, an administrative dataset recording all hospital admissions and procedures in England, to find evidence of change in the use of various surgical procedures for urinary incontinence from 2000 to 2012. Results For the treatment of SUI, a general increase in the use of synthetic mid‐urethral tapes, such as tension‐free vaginal tape (TVTO) and transobturator tape (TOT), was observed, while there was a significant decrease in colposuspension procedures over the same period. The number of procedures to remove TVT and TOT has also increased in recent years. In the treatment of overactive bladder and UUI, there has been a significant increase in the use of botulinum toxin A and neuromodulation in recent years. This coincided with a steady decline in the recorded use of clam ileocystoplasty. A steady increase was observed in the insertion of artificial urinary sphincter (AUS) devices in men, related to PPI. Conclusions Mid‐urethral synthetic tapes now represent the mainstream treatment of SUI in women, but tape‐related complications have led to an increase in procedures to remove these devices. The uptake of botulinum toxin A and sacral neuromodulation has led to fewer clam ileocystoplasty procedures being performed. The steady increase in insertions of AUSs in men is unsurprising and reflects the widespread uptake of radical prostatectomy in recent years. There are limitations to results sourced from the HES database, with potential inaccuracy of coding; however, these data support the trends observed by experts in this field.
      PubDate: 2014-05-22T03:16:52.448775-05:
      DOI: 10.1111/bju.12650
       
  • Low free testosterone levels predict disease reclassification in men with
           prostate cancer undergoing active surveillance
    • Authors: Ignacio F. San Francisco; Pablo A. Rojas, William C. DeWolf, Abraham Morgentaler
      Abstract: Objective To determine whether total testosterone and free testosterone levels predict disease reclassification in a cohort of men with prostate cancer (PCa) on active surveillance (AS). Patients and Methods Total testosterone and free testosterone concentrations were determined at the time the men began the AS protocol. Statistical analysis was performed using Student's t‐test and a chi‐squared test to compare groups. Odds ratios (ORs) with 95% confidence intervals (CIs) were obtained using univariate logistic regression. Receiver–operator characteristic curves were generated to determine the investigated testosterone thresholds. Kaplan–Meier curves were used to estimate time to disease reclassification. A Cox proportional hazard regression model was used for multivariate analysis. Results A total of 154 men were included in the AS cohort, of whom 54 (35%) progressed to active treatment. Men who had disease reclassification had significantly lower free testosterone levels than those who were not reclassified (0.75 vs 1.02 ng/dL, P = 0.03). Men with free testosterone levels
      PubDate: 2014-05-04T21:48:04.430901-05:
      DOI: 10.1111/bju.12682
       
  • Role of urinary cations in the aetiology of bladder symptoms and
           interstitial cystitis
    • Authors: C. Lowell Parsons; Timothy Shaw, Zoltan Berecz, Yongxuan Su, Paul Zupkas, Sulabha Argade
      Abstract: Objectives To identify and characterise urinary cationic metabolites, defined as toxic factors, in patients with interstitial cystitis (IC) and in control subjects. To evaluate the cytotoxicity of the urinary cationic metabolite fraction of patients with IC vs control subjects and of individual metabolites in cultured urothelial cells. Subjects and Methods Cationic fractions (CFs) were isolated from the urine specimens of 62 patients with IC and 33 control subjects by solid‐phase extraction. CF metabolites were profiled using C18 reverse‐phase high performance liquid chromatography (RP‐HPLC) with UV detection, quantified by area‐under‐the‐peaks using known standards, and normalized to creatinine. RP‐HPLC and liquid chromatography (LC)‐mass spectrometry (MS)/tandem MS (MS/MS) were used to identify major CF peaks. HTB‐4 urothelial cells were used to determine the cytotoxicity of CFs and of individual metabolites with and without Tamm–Horsfall protein (THP). Results RP‐HPLC analysis showed that metabolite quantity was twofold higher in patients with IC compared with control subjects. The mean (sem) for control subjects vs patients was 3.1 (0.2) vs 6.3 (0.5) mAU*min/μg creatinine (P < 0.001). LC‐MS identified 20 metabolites. Patients with IC had higher levels of modified nucleosides, amino acids and tryptophan derivatives compared with control subjects. The CF cytotoxicity was higher for patients with IC compared with control subjects. The mean (sem) for control subjects vs patients was −2.3 (2.0)% vs 36.7 (2.7)% (P < 0.001). A total of 17 individual metabolites were tested for their cytotoxicity. Cytotoxicity data for major metabolites were all significant (P < 0.001): 1‐methyladenosine (51%), 5‐methylcytidine (36%), 1‐methyl guanine (31%), N4‐acetylcytidine (24%), N7‐methylguanosine (20%) and L‐Tryptophan (16%). These metabolites were responsible for higher toxicity in patients with IC. The toxicity of all metabolites was significantly lower in the presence of control THP (P < 0.001). Conclusions Major urinary cationic metabolites were characterised and found to be present in higher amounts in patients with IC compared with control subjects. The cytotoxicity of cationic metabolites in patients with IC was significantly higher than in control subjects, and control THP effectively lowered the cytotoxicity of these metabolites. These data provide new insights into toxic factor composition as well as a framework in which to develop new therapeutic strategies to sequester their harmful activity, which may help relieve the bladder symptoms associated with IC.
      PubDate: 2014-04-16T22:25:25.708897-05:
      DOI: 10.1111/bju.12603
       
  • In vitro fragmentation efficiency of holmium:
           yttrium‐aluminum‐garnet (YAG) laser lithotripsy – a
           comprehensive study encompassing different frequencies, pulse energies,
           total power levels and laser fibre diameters
    • Authors: Peter Kronenberg; Olivier Traxer
      Pages: n/a - n/a
      Abstract: Objective To assess the fragmentation (ablation) efficiency of laser lithotripsy along a wide range of pulse energies, frequencies, power settings and different laser fibres, in particular to compare high‐ with low‐frequency lithotripsy using a dynamic and innovative testing procedure free from any human interaction bias. Materials and Methods An automated laser fragmentation testing system was developed. The unmoving laser fibres fired at the surface of an artificial stone while the stone was moved past at a constant velocity, thus creating a fissure. The lithotripter settings were 0.2–1.2 J pulse energies, 5–40 Hz frequencies, 4–20 W power levels, and 200 and 550 μm core laser fibres. Fissure width, depth, and volume were analysed and comparisons between laser settings, fibres and ablation rates were made. Results Low frequency‐high pulse energy (LoFr‐HiPE) settings were (up to six times) more efficient than high frequency‐low pulse energy (HiFr‐LoPE) at the same power levels (P < 0.001), as they produced deeper (P < 0.01) and wider (P < 0.001) fissures. There were linear correlations between pulse energy and fragmentation volume, fissure width, and fissure depth (all P < 0.001). Total power did not correlate with fragmentation measurements. Laser fibre diameter did not affect fragmentation volume (P = 0.81), except at very low pulse energies (0.2 J), where the large fibre was less efficient (P = 0.015). Conclusions At the same total power level, LoFr‐HiPE lithotripsy was most efficient. Pulse energy was the key variable that drove fragmentation efficiency. Attention must be paid to prevent the formation of time‐consuming bulky debris and adapt the lithotripter settings to one's needs. As fibre diameter did not affect fragmentation efficiency, small fibres are preferable due to better scope irrigation and manoeuvrability.
      PubDate: 2014-04-16T03:55:29.785349-05:
      DOI: 10.1111/bju.12567
       
  • Robotic retroperitoneal partial nephrectomy: a step‐by‐step
           guide
    • Abstract: Objective To describe a step‐by‐step guide for successful implementation of the retroperitoneal approach to robotic partial nephrectomy (RPN) Patients and Methods The patient is placed in the flank position and the table fully flexed to increase the space between the 12th rib and iliac crest. Access to the retroperitoneal space is obtained using a balloon‐dilating device. Ports include a 12‐mm camera port, two 8‐mm robotic ports and a 12‐mm assistant port placed in the anterior axillary line cephalad to the anterior superior iliac spine, and 7–8 cm caudal to the ipsilateral robotic port. Results Positioning and port placement strategies for successful technique include: (i) Docking robot directly over the patient's head parallel to the spine; (ii) incision for camera port ≈1.9 cm (1 fingerbreadth) above the iliac crest, lateral to the triangle of Petit; (iii) Seldinger technique insertion of kidney‐shaped balloon dilator into retroperitoneal space; (iv) Maximising distance between all ports; (v) Ensuring camera arm is placed in the outer part of the ‘sweet spot’. Conclusion The retroperitoneal approach to RPN permits direct access to the renal hilum, no need for bowel mobilisation and excellent visualisation of posteriorly located tumours.
       
  • Association of type of renal surgery and access to robotic technology for
           kidney cancer: results from a population‐based cohort
    • Abstract: Objective To evaluate the relationship between partial nephrectomy (PN) and hospital availability of robot‐assisted surgery from a population‐based cohort in the USA. Methods After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association survey from 2006 to 2008, we identified 21 179 patients who underwent either PN or radical nephrectomy (RN) for renal cell carcinoma (RCC). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN. Results We identified 4832 (22.8%) and 16 347 (77.2%) patients who were treated for RCC with PN and RN, respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio [OR] 2.77; P < 0.001), urban centres (OR 3.66; P < 0.001) and American College of Surgeons (ACOS)‐designated cancer centres (OR: 1.10; P < 0.05) compared with non‐academic, rural and non‐ACOS‐designated cancer centre hospitals, respectively. Robot‐assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability (OR 1.28; P < 0.001). Conclusions Although academic and urban locations are established factors that affect the receipt of PN for RCC, the availability of robot‐assisted surgery at a hospital was also independently associated with higher use of PN. Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN.
       
  • Single nucleotide polymorphisms in fibroblast growth factor 23 gene,
           FGF23, are associated with prostate cancer risk
    • Abstract: Objective To determine whether sequence variants within the FGF23 gene are associated with the risk of developing prostate cancer in a Korean population. Patients and Methods Five common single nucleotide polymorphisms (SNPs) in the FGF23 gene were assessed in 272 patients with prostate cancer and 173 control subjects with benign prostatic hyperplasia. Single‐locus analyses were conducted using conditional logistic regression. In addition, we performed a haplotype analysis for the five FGF23 SNPs tested. Results Three SNPs in the FGF23 gene (rs11063118, rs13312789 and rs7955866) were associated with an increased risk of prostate cancer in our study population. Odds ratios for homozygous variants vs wild‐type variants ranged from 1.68 (95% confidence interval [CI]: 1.15–2.46) to 1.79 (95% CI: 1.16–2.75). Conclusion This is the first study showing that genetic variations in FGF23 increase prostate cancer susceptibility.
       
  • Science made simple: tissue microarrays (TMAs)
    •  
  • Prognostic and diagnostic implications of epithelial cell
           adhesion/activating molecule (EpCAM) expression in renal tumours: a
           retrospective clinicopathological study of 948 cases using tissue
           microarrays
    • Abstract: Objective To evaluate the expression and prognostic value of epithelial cell adhesion/activating molecule (EpCAM) in a large set of renal cell carcinomas (RCCs) using a tissue microarray (TMA) approach. Material and Methods We studied the immunohistochemical expression and overexpression of EpCAM on TMAs containing formalin‐fixed, paraffin‐embedded samples of 948 patients with documented renal tumours. EpCAM expression was defined as the presence of a specific membranous staining in >5% of the tumour cells. EpCAM overexpression was specified by calculating a total staining score (score range 0–12) as the product of a proportion score and an intensity score, and defined as a score >4. Results Of 948 cases, 927 (97.8%) were evaluable morphologically (haematoxylin and eosin stain). EpCAM expression was found in 233/642 (36.3%), 126/155 (81.3%), 54/68 (78.3%), 17/45 (37.8%), 13/30 (43.3%) of clear‐cell RCC, papillary RCC (pRCC), chromophobe RCC (cpRCC), oncocytomas and other unclassified tumour types, respectively. Log‐rank tests showed a significantly longer overall survival (OS [P = 0.047]) and a trend of EpCAM expression to be associated with a longer progression‐free survival (PFS) in all RCC entities (P = 0.065). EpCAM overexpression was significantly correlated with a better PFS in all RCC subtypes, cpRCC and pRCC (P = 0.011, 0.043 and 0.025, respectively). In multivariate analysis EpCAM overexpression was an independent marker for longer PFS in all RCC entities as well as in high grade RCC (P = 0.009 and P = 0.010, respectively). Conclusions The histological subtypes associated with a high rate of EpCAM expression were cpRCC and pRCC. This retrospective analysis demonstrated a trend towards longer OS and PFS for all major RCC subtypes. EpCAM expression had significant prognostic value in patients with cpRCC and pRCC. Furthermore, EpCAM overexpression in high grade RCC may be a helpful marker for prognostication.
       
  • A clinical evaluation of a sensor to detect blockage due to crystalline
           biofilm formation on indwelling urinary catheters
    • Abstract: Objective To test the performance and acceptability of an early warning sensor to predict encrustation and blockage of long‐term indwelling urinary catheters. Patients and Methods In all, 17 long‐term indwelling catheter users, 15 ‘blockers’ and two ‘non‐blockers’ (controls) were recruited; 11 participants were followed prospectively until catheter change, three withdrew early and three did not start. Two sensors were placed in series between the catheter and the urine bag at catheter change. The sensor nearest the bag was changed at the same time as the bag change (weekly); the sensor nearest the catheter remained in situ for the duration of the catheter's life. Bacteriology and pH determinations were performed on urine samples at each bag, sensor and catheter change. The colour of the sensors was recorded daily. On removal, each sensor and the catheter were examined for visible evidence of encrustation and blockage. Participants were asked to keep a daily diary to record colour change and any other relevant observations and to complete a psychosocial impact of assistive devices tool at the end of the study. Participants and carers/healthcare professionals (when involved in urine bag or catheter change) were asked to complete a questionnaire about the sensor. Results Urease‐producing bacteria were isolated from seven of the 14 patients (including early withdrawals; P. mirabilis in four, Morganella or Providencia in three). In six of the seven patients the sensors turned blue‐black; two of these were early withdrawals, two went to planned catheter change (one of these was recruited as a ‘non‐blocker’) and three had catheter blockage. The number of days of catheterisation before blockage was 22, 23 and 25 days, and the sensor changed colour within 24–48 h after insertion. The urine mean (range) pH of the sensors that turned blue‐black was 7.6 (5.5–9.0) and of the sensors that remained yellow 6.1 (5.1–7.5). The sensor was generally well‐received and was positive in the psychosocial assessment. Conclusions The sensor is a useful indicator of urine pH and of the conditions that lead to catheter blockage. It may be particularly useful for new indwelling catheter users. To be a universally acceptable predictor of catheter blockage, the time from sensor colour change to blockage needs to be reduced.
       
  • Perioperative outcomes of 6042 nephrectomies in 2012:
           surgeon‐reported results in the UK from the British Association of
           Urological Surgeons (BAUS) nephrectomy database
    • Abstract: Objective To present the perioperative outcomes from the British Association of Urological Surgeons (BAUS) nephrectomy dataset for 2012, the first year of public reporting of individual surgeon outcomes in the UK. Patients and Methods All nephrectomies performed in the year 2012 and recorded in the database were analysed. These were divided into simple nephrectomy (SN), partial nephrectomy (PN), radical nephrectomy (RN), and nephroureterectomy (NU). The estimated capture rate for nephrectomy was 80%. The outcomes measured were 30‐day mortality (30‐DM), Clavien‐Dindo complications grade ≥III, blood transfusion, conversion to open, and length of stay. Results The overall 30‐DM was 0.55% (SN 0.53%; PN 0.10%; RN 0.52%; NU 1.27%). Clavien‐Dindo complications grade ≥III were recorded in 3.9% of nephrectomies (SN 4.3%; PN 5.4%; RN 3.1%; NU 4.5%). Blood transfusion was required during surgical admission for 8.4% of nephrectomies (SN 5.2%; PN 3.4%; RN 11.1%; NU 8.3%). Conversion to open was carried out in 5.5% of minimally invasive nephrectomies (SN 6.1%; PN 4.0%; RN 5.5%; NU 5.6%). Open nephrectomy patients remained in hospital for a median of 6 days (SN 7; PN 5; RN 7; NU 8 days), which was higher than the median 4‐day stay (SN 3; PN 4; RN 4; NU 5 days) for minimally invasive surgery. Conclusions Nephrectomy in 2012 was a safe procedure with morbidity and mortality rates comparable with or less than published series. The collection of surgeon‐specific data should be iterative with further refinement of data categories, support for the collection process and independent validation of results.
       
  • Quantification of skeletal metastases in castrate‐resistant prostate
           cancer predicts progression‐free and overall survival
    • Abstract: Objective To report a simplified and effective method for substratification of M1 castrate‐resistant prostate cancer (CRPC) by correlating progression‐free (PFS) and overall survival (OS) with simple quantification of skeletal metastases. Patients and Methods In all, 561 men with M1 CRPC were studied longitudinally. Individual bone scan disease burden, quantified by counting bone metastasis number, was correlated with clinical outcome using specific threshold points of 1–4, 5–20 and >20 detectable lesions. Results Patients with a higher metastasis number had a shorter PFS and OS (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.7–2.4; P < 0.001). Patients with 1–4 metastases had much better PFS and OS than those with 5–20 metastases. The median PFS and OS in the latter was 10.9 (95% CI 8.4–12.8) and 22.1 (95% CI: 18.5–24.5) months, respectively. PFS and OS for patients with >20 metastases were shorter still [median 5.3 (95% CI 3.4–6.9) months and 13.3 (95% CI 11.3–17.6) months, respectively]. Dichotomising into cohorts with 1–4 and ≥5 metastases, the latter group had considerably poorer PFS [8.4 (95% CI 6.8–10.3) months; P < 0.001) and OS [18.7 (95% CI 17.5–22.1) months; P < 0.001]. Conclusions Dichotomising patients with CRPC into cohorts with 1–4 or ≥5 skeletal metastases identifies a better and a worse cohort in a manner that is easy and clinically accessible. This simple method facilitates disease stratification and patient management, enabling clinicians to counsel patients more effectively about long‐term outcomes and to help select intervention therapies more effectively.
       
  • Penile prosthesis insertion in patients with refractory ischaemic
           priapism: early vs delayed implantation
    • Abstract: Objective To compare the long‐term results of early and delayed insertion of a penile prosthesis (PP) in men with refractory ischaemic priapism (IP). Patients and Methods Early insertion of a PP was carried out in 68 men with IP within a median of 7 days from the onset of priapism, while 27 had delayed insertion after a median of 5 months. The results for sexual ability, satisfaction and subjective penile shortening were assessed by questioning at follow‐up visits. Results In the early group, a malleable and an inflatable PP were implanted in 64 and four patients, respectively. After a median follow‐up of 17 months, six patients needed revision surgery due to infection and curvature. Patient's satisfaction rate and ability to have sexual intercourse was 96%. In the delayed group, a malleable PP was inserted in 12 patients and an inflatable in the remaining 15. In all, 80% of the patients required a second corporotomy and downsized cylinders due to dense fibrosis. After a median follow‐up of 21 months, seven patients required revision surgery due to infection, erosion and mechanical failure. In all, 25 patients were able to engage in sexual intercourse but the satisfaction rate was only 60% mainly due to significant penile shortening. Conclusions Early PP implantation should be the preferred option in patients with IP, as the procedure is technically easier, has less complication rates and allows greater preservation of penile length.
       
  • Can supervised exercise prevent treatment toxicity in patients with
           prostate cancer initiating androgen‐deprivation therapy: a
           randomised controlled trial
    • Abstract: Objective To determine if supervised exercise minimises treatment toxicity in patients with prostate cancer initiating androgen‐deprivation therapy (ADT). This is the first study to date that has investigated the potential role of exercise in preventing ADT toxicity rather than recovering from established toxicities. Patients and Methods Sixty‐three men scheduled to receive ADT were randomly assigned to a 3‐month supervised exercise programme involving aerobic and resistance exercise sessions commenced within 10 days of their first ADT injection (32 men) or usual care (31 men). The primary outcome was body composition (lean and fat mass). Other study outcomes included bone mineral density, physical function, blood biomarkers of chronic disease risk and bone turnover, general and prostate cancer‐specific quality of life, fatigue and psychological distress. Outcomes were compared between groups using analysis of covariance adjusted for baseline values. Results Compared to usual care, a 3‐month exercise programme preserved appendicular lean mass (P = 0.019) and prevented gains in whole body fat mass, trunk fat mass and percentage fat with group differences of −1.4 kg (P = 0.001), −0.9 kg (P = 0.008) and −1.3% (P < 0.001), respectively. Significant between‐group differences were also seen favouring the exercise group for cardiovascular fitness (peak oxygen consumption 1.1 mL/kg/min, P = 0.004), muscular strength (4.0–25.9 kg, P ≤ 0.026), lower body function (–1.1 s, P < 0.001), total cholesterol: high‐density lipoprotein‐cholesterol ratio (–0.52, P = 0.028), sexual function (15.2, P = 0.028), fatigue (3.1, P = 0.042), psychological distress (–2.2, P = 0.045), social functioning (3.8, P = 0.015) and mental health (3.6–3.8, P ≤ 0.022). There were no significant group differences for any other outcomes. Conclusion Commencing a supervised exercise programme involving aerobic and resistance exercise when initiating ADT significantly reduced treatment toxicity, while improving social functioning and mental health. Concurrent prescription of supervised exercise when initiating ADT is therefore advised to minimise morbidity associated with severe hypogonadism.
       
  • External validation of preoperative and postoperative nomograms for
           prediction of cancer‐specific survival, overall survival and
           recurrence after robot‐assisted radical cystectomy for urothelial
           carcinoma of the bladder
    • Abstract: Objective To externally validate currently available bladder cancer nomograms for prediction of all‐cause survival (ACS), cancer‐specific survival (CSS), other‐cause mortality (OCM) and progression‐free survival (PFS). Patients and Methods Retrospective analysis of a prospectively maintained database of 282 patients who underwent robot‐assisted radical cystectomy (RARC) at a single institution was performed. The Bladder Cancer Research Consortium (BCRC), International Bladder Cancer Nomogram Consortium (IBCNC) and Lughezzani nomograms were used for external validation, and evaluation for accuracy at predicting oncological outcomes. The 2‐ and 5‐year oncological outcomes were compared, and nomogram performance was evaluated through measurement of the concordance (c‐index) between nomogram‐derived predicted oncological outcomes and observed oncological outcomes. Results The median (range) patient age was 70 (36–90) years. At a mean follow‐up of 20 months, local or distant disease recurrence developed in 30% of patients. With an overall mortality rate of 33%, 17% died from bladder cancer. The actuarial 2‐ and 5‐year PFS after RARC was 62% (95% confidence interval [CI] 54–68) and 55% (95% CI 46–63), respectively. The actuarial 2‐ and 5‐year ACS was 66% (95% CI 59–72) and 47% (95% CI 37–55), respectively, and the 2‐ and 5‐year CSS was 81% (95% CI 74–86) and 67% (95% CI 57–76), respectively. The PFS c‐index for IBCNC was 0.70 at 5 years, and for BCRC was 0.77 at both the 2 and 5 years. The accuracy of ACS and CSS prediction was evaluated using the BCRC and Lughezzani nomograms. Using the BCRC nomogram, c‐indices of for 2‐ and 5‐year ACS were each 0.73 and c‐indices for 2‐ and 5‐year CSS were 0.70 each. The performance of Lughezzani nomogram for 5‐year ACS, cancer‐specific mortality and OCM were 0.73, 0.72 and 0.40, respectively. The BCRC nomogram prediction of advanced pathological stage and lymph node metastasis was modest, with c‐indices of 0.66 and 0.61, respectively. Conclusions Bladder cancer nomograms available from the current open RC literature adequately predict ACS, CSS and PFS after RARC. However, prediction of advanced tumour stage and lymph node metastasis was modest and the Lughezzani nomogram failed to predict OCM.
       
  • Retzius‐sparing robot‐assisted laparoscopic radical
           prostatectomy: combining the best of retropubic and perineal approaches
    • Abstract: Objective To compare the early peri‐operative, oncological and continence outcomes of Retzius‐sparing robot‐assisted laparoscopic radical prostatectomy (RALP) with those of conventional RALP. Materials and Methods Data from 50 patients who underwent Retzius‐sparing RALP and who had at least 6 months of follow‐up were prospectively collected and compared with a database of patients who underwent conventional RALP. Propensity‐score matching was performed using seven preoperative variables, and postoperative variables were compared between the groups. Results A total of 581 patients who had undergone RALP were evaluated in the present study. Although preoperative characteristics were different before propensity‐score matching, these differences were resolved after matching. There were no significant differences in mean length of hospital stay, estimated blood loss, intra‐ and postoperative complication rates, pathological stage of disease, Gleason scores, tumour volumes and positive surgical margins between the conventional RALP and Retzius‐sparing RALP groups. Console time was shorter for Retzius‐sparing RALP. Recovery of early continence (defined as 0 pads used) at 4 weeks after RALP was significantly better in the Retzius‐sparing RALP group than in the conventional RALP group. Conclusions The present results suggest that Retzius‐sparing RALP, although technically more demanding, was as feasible and effective as conventional RALP, and also led to a shorter operating time and faster recovery of early continence. Retzius‐sparing RALP was also reproducible and achievable in all cases.
       
  • Lateral temperature spread of monopolar, bipolar and ultrasonic
           instruments for robot‐assisted laparoscopic surgery
    • Abstract: Objective To assess critical heat spread of cautery instruments used in robot‐assisted laparoscopic (RAL) surgery. Materials and Methods Thermal spread along bovine musculofascial tissues was examined by infrared camera, histology and enzyme assay. Currently used monopolar, bipolar and ultrasonic laparoscopic instruments were investigated at various power settings and application times. The efficacy of using an additional Maryland clamp as a heat sink was evaluated. A temperature of 45 °C was considered the threshold temperature for possible nerve damage. Results Monopolar instruments exhibited a mean (sem) critical thermal spread of 3.5 (2.3) mm when applied at 60 W for 1 s. After 2 s, the spread was >20 mm. For adjustable bipolar instruments the mean (sem) critical thermal spread was 2.2 (0.6) mm at 60 W and 1 s, and 3.6 (1.3) mm at 2 s. The PK and LigaSure forceps had mean (sem) critical thermal spreads of 3.9 (0.8) and 2.8 (0.6) mm respectively, whereas the ultrasonic instrument reached 2.9 (0.8) mm. Application of an additional Maryland clamp as a heat sink, significantly reduced the thermal spread. Histomorphometric analyses and enzyme assay supported these findings. Conclusions All coagulation devices used in RAL surgery have distinct thermal spreads depending on power setting and application time. Cautery may be of concern due to lateral temperature spread, causing potential damage to sensitive structures including nerves. Our results provide surgeons with a resource for educated decision‐making when using coagulation devices during robotic procedures.
       
  • Neoadjuvant chemotherapy for bladder cancer does not increase risk of
           perioperative morbidity
    • Abstract: Objective To determine whether neoadjuvant chemotherapy (NAC) is a predictor of postoperative complications, length of stay (LOS), or operating time after radical cystectomy (RC) for bladder cancer. Patients and Methods A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed to identify patients receiving NAC before RC from 2005 to 2011. Bivariable and multivariable analyses were used to determine whether NAC was associated with 30‐day perioperative outcomes, e.g. complications, LOS, and operating time. Results Of the 878 patients who underwent RC for bladder cancer in our study, 78 (8.9%) received NAC. Excluding those patients who were ineligible for NAC due to renal insufficiency, 78/642 (12.1%) received NAC. In all, 457 of the 878 patients (52.1%) undergoing RC had at least one complication ≤30 days of RC, including 43 of 78 patients (55.1%) who received NAC and 414 of 800 patients (51.8%) who did not (P = 0.58). On multivariable logistic regression, NAC was not a predictor of complications (P = 0.87), re‐operation (P = 0.16), wound infection (P = 0.32), or wound dehiscence (P = 0.32). Using multiple linear regression, NAC was not a predictor of increased operating time (P = 0.24), and patients undergoing NAC had a decreased LOS (P = 0.02). Conclusions Our study is the first large multi‐institutional analysis specifically comparing complications after RC with and without NAC. Using a nationally validated, prospectively maintained database specifically designed to measure perioperative outcomes, we found no increase in perioperative complications or surgical morbidity with NAC. Considering these findings and the well‐established overall survival benefit over surgery alone, efforts are needed to improve the uptake of NAC.
       
  • Nephron‐sparing management vs radical nephroureterectomy for
           low‐ or moderate‐grade, low‐stage upper tract urothelial
           carcinoma
    • Abstract: Objective To compare overall and cancer‐specific outcomes between patients with upper tract urothelial carcinoma (UTUC) managed with either radical nephroureterectomy (RNU) or nephron‐sparing measures (NSM) using a large population‐based dataset. Patients and Methods Using Surveillance, Epidemiology, and End Results (SEER) data, patients diagnosed with low‐ or moderate‐grade, localised non‐invasive UTUC were stratified into two groups: those treated with RNU or NSM (observation, endoscopic ablation, or segmental ureterectomy). Cancer‐specific mortality (CSM) and other‐cause mortality (OCM) rates were determined using cumulative incidence estimators. Adjusting for clinical and pathological characteristics, the associations between surgical type, all‐cause mortality and CSM were tested using Cox regressions and Fine and Gray regressions, respectively. Results Of 1227 patients [mean (sd) age 70.2 (11.00) years, 63.2% male] meeting inclusion criteria, 907 (73.9%) and 320 (26.1%) patients underwent RNU and NSM for low‐ or moderate‐grade, low‐stage UTUC from 1992 to 2008. Patients undergoing NSM were older (mean age 71.6 vs 69.7 years, P < 0.01) with a greater proportion of well‐differentiated tumours (26.3% vs 18.0%, P = 0.001). While there were differences in OCM between the groups (P < 0.01), CSM trends were equivalent. After adjustment, RNU treatment was associated with improved non‐cancer cause survival [hazard ratio (HR) 0.78, confidence interval [CI] 0.64–0.94) while no association with CSM was demonstrable (HR 0.89, CI 0.63–1.26). Conclusions Patients with low‐ or moderate‐grade, low‐stage UTUC managed through NSM are older and are more likely to die of other causes, but they have similar CSM rates to those patients managed with RNU. These data may be useful when counselling patients with UTUC with significant competing comorbidities.
       
  • Meta‐analysis of robot‐assisted vs conventional laparoscopic
           and open pyeloplasty in children
    • Abstract: Objective To critically analyse outcomes for robot‐assisted pyeloplasty (RAP) vs conventional laparoscopic pyeloplasty (LP) or open pyeloplasty (OP) by systematic review and meta‐analysis of published data. Patients and Methods Studies published up to December 2013 were identified from multiple literature databases. Only comparative studies investigating RAP vs LP or OP in children were included. Meta‐analysis was performed using random‐effects modelling. Heterogeneity, subgroup analysis, and quality scoring were assessed. Effect sizes were estimated by pooled odds ratios and weighted mean differences. Primary outcomes investigated were operative success, re‐operation, conversions, postoperative complications, and urinary leakage. Secondary outcome measures were estimated blood loss (EBL), length of hospital stay (LOS), operating time (OT), analgesia requirement, and cost. Results In all, 12 observational studies met inclusion criteria, reporting outcomes of 384 RAP, 131 LP, and 164 OP procedures. No randomised controlled trials were identified. Pooled analyses determined no significant differences between RAP and LP or OP for all primary outcomes. Significant differences in favour of RAP were found for LOS (vs LP and OP). Borderline significant differences in favour of RAP were found for EBL (vs OP). OT was significantly longer for RAP vs OP. Limited evidence indicates lower opiate analgesia requirement for RAP (vs LP and OP), higher total costs for RAP vs OP, and comparable costs for RAP vs LP. Conclusions Existing evidence shows largely comparable outcomes amongst surgical techniques available to treat pelvi‐ureteric junction obstruction in children. RAP may offer shortened LOS, lower analgesia requirement (vs LP and OP), and lower EBL (vs OP); but compared with OP, these gains are at the expense of higher cost and longer OT. Higher quality evidence from prospective observational studies and clinical trials is required, as well as further cost‐effectiveness analyses. Not all perceived benefits of RAP are easily amenable to quantitative assessment.
       
  • Impact of the type of ureteroileal anastomosis on renal function measured
           by diuretic scintigraphy: long‐term results of a prospective
           randomized study
    • Abstract: Objective To determine the long‐term effects of the direct refluxing‐type ureteroileal anastomosis technique with those of an antireflux technique on individual renal units, using diuretic scintigraphy in a prospectively randomized study. Patients and Methods Between 2002 and 2006, a prospective randomized study was conducted on 102 patients undergoing radical cystectomy and urinary diversion. In every patient, both ureters were randomized to be implanted using a direct refluxing technique or an antireflux, serous‐lined extramural tunnel (SLET) technique. Renal function (RF) was evaluated using 99mTc‐MAG‐3 diuretic scintigraphy. The serial changes in corrected glomerular filtration rate (cGFR) for each technique and for each side were compared. Results Over a median follow‐up of 6 years, the patients in both the direct refluxing and the SLET technique groups were found to have a significant reduction in mean (sd) cGFR between baseline and last follow‐up: cGFR decreased from 59.4 (12.4) to 45.6 (15.3) mL/min (P < 0.001) and from 54.3 (11.2) to 46.3 (12.8) mL/min (P = 0.002), respectively. Five patients (4.9%) in the SLET group developed obstruction (four left‐sided and one right‐sided) compared with one (0.9%) in the direct refluxing group (right‐sided). The onset of obstruction was noted 1–7 months after radical cystectomy. There was no significant difference between the groups in reductions in cGFR across the timepoints. Comparison of the two techniques according to the side of ureter implantation showed that the direct refluxing technique trended towards better functional outcomes on the left side. Conclusions There was no observed difference in the RF of individual renal units between the SLET and the direct refluxing groups in the long term. The need to incorporate an antireflux technique should be questioned and tailored according to the surgeon's experience and confidence.
       
  • Comparison of expected treatment outcomes, obtained using risk models and
           international guidelines, with observed treatment outcomes in a Dutch
           cohort of patients with non‐muscle‐invasive bladder cancer
           treated with intravesical chemotherapy
    • Abstract: Objective To compare the risks according to the American Urological Association (AUA), EAU, European Organization for Research and Treatment of Cancer (EORTC) and Club Urológico Español de Tratamiento Oncologico (CUETO) classifications with real outcomes in a cohort of patients in the Netherlands, and to confirm that patients who were undertreated according to these risk models have worse outcomes than adequately treated patients. Patients and Methods Patients treated with complete transurethral resection of bladder tumour and intravesical chemotherapy were included. Not all patients would have received intravesical chemotherapy had they been treated to current standards, and thus comparison of the observed outcomes in our Dutch cohort vs expected outcomes based on the EORTC risk tables and CUETO scoring model was possible. The cohort was reclassified according to the definitions of five index patients (IPs), as defined by the AUA guidelines, and three risk groups, defined according to the EAU guidelines, to compare the outcomes of undertreated patients with those of adequately treated patients. Results A total of 1001 patients were available for comparison with the AUA definitions and 728 patients were available for comparison with the EORTC and CUETO models. There was a large overlap between the observed outcomes and expected recurrence and progression probabilities when comparison was made using the EORTC risk tables. The observed recurrence outcomes were in general higher than the expected probabilities according to the CUETO risk classification, especially in the long term. No differences in progression were found when comparing these two models to the Dutch cohort. Patients who were undertreated according to the guidelines showed, in general, a higher risk of developing recurrence and progression. Limitations are i.a. its retrospective nature and the differences in grading system. Conclusion Comparisons between the observed outcomes in our Dutch cohort and the expected outcomes based on EAU and CUETO risk models and the EORTC and AUA guidelines showed that lack of adherence to existing guidelines translates into worse outcomes.
       
  • Progression and predictors of physical activity levels after radical
           prostatectomy
    • Abstract: Objective To investigate the progression of all aspects (total, occupational, sports, household) of physical activity (PA) over time after radical prostatectomy (RP) and to find predictive factors for a decrease in PA. Patients and Methods In all, 240 men planned for open or robot‐assisted RP were analysed. All patients completed the Flemish Physical Activity Computerised Questionnaire before RP concerning PA over the past year and at 6 weeks, 3, 6 and 12 months after RP for the PA of the past month. A linear model for repeated measures was used to evaluate the progression of continuous variables over time and the effect of various predictors for the progression of patients over time. A logistic regression model for repeated measures was used to evaluate binary measures. Results Total, occupational, sports and household PA levels were significantly decreased at 6 weeks after RP, but recovered quickly to approximately baseline levels from that time. Predictive factors for decreased PA levels at 6 weeks after RP were a younger age (total PA level), being unskilled/semi‐skilled (occupational PA level) and being unemployed/retired (household PA level). RP type (open vs robot‐assisted) did not influence the different PA levels at 6 weeks, 3, 6 or 12 months after RP. The severity of first day incontinence and urine loss measured at 6 weeks and 3, 6 and 12 months after RP significantly affected total and/or household PA level at all time‐points. Conclusions This is the first study to investigate the progression of all aspects of PA (total, occupational, sports and household) after RP and to find predictive factors for a decrease in PA. All PA levels were significantly decreased at 6 weeks after RP and recovered quickly to approximately baseline levels from that time. Patients that had robot‐assisted RP did not have a faster recovery of PA than those that had open RP. Severity of first day incontinence and urine loss measured at 6 weeks and 3, 6 and 12 months after RP were significantly related to total and/or household PA level at all time‐points.
       
  • Malnourishment in bladder cancer and the role of immunonutrition at the
           time of cystectomy: an overview for urologists
    • Abstract: The ‘gold standard’ treatment for patients with carcinoma invading the bladder muscle is radical cystectomy (RC). Such patients are known to be at risk of malnutrition because of age and disease factors. Current evidence has established the nutritional and immunological benefits of immune‐enhancing nutritional supplements in upper gastrointestinal surgery. There are currently no guidelines for immunonutrition (IM) use in urology and bladder cancer specifically. We carried out a systematic review of the available literature in the MEDLINE/Embase database. We assessed the rates of malnutrition in RC cohorts and analysed the clinical impacts of nutritional deficiency. The impact of immune‐enhancing supplements was also investigated in RC cohorts with regard to postoperative outcomes. The prevalence of severe malnutrition was found to be 16–22%. There was a consistent association of malnourished patients with adverse postoperative outcomes in terms of mortality and morbidity. There is a paucity of data regarding IM in urological cohorts. Postoperative IM in RC was not found to have significant benefits beyond early return to a normal diet. There is not enough evidence in malnourished urological study cohorts to establish a consensus on IM. Until there are more well‐controlled comparative effective studies or randomized trials, the role of IM should be considered investigational in patients with bladder cancer.
       
  • Professor John M. Fitzpatrick 1948–2014: a life in the fast lane
    •  
  • Routine data expose a need for change
    •  
  • Pushing the robot‐assisted prostatectomy envelope – to the
           safety limits' Better outcomes
    •  
  • Upper tract urothelial carcinoma: do we really need to burn down the
           house'
    •  
  • Unveiling the surgical risk associated with neoadjuvant chemotherapy in
           bladder cancer
    •  
  • The importance of knowing testosterone levels in patients with prostate
           cancer
    •  
  • Use of advanced treatment technologies among men at low risk of dying from
           prostate cancer
    •  
  • Recent insights into NF‐κB signalling pathways and the link
           between inflammation and prostate cancer
    • Abstract: Inflammation is involved in regulation of cellular events in prostate carcinogenesis through control of the tumour micro‐environment. A variety of bone marrow‐derived cells, including CD4+ lymphocytes, macrophages and myeloid‐derived suppressor cells, are integral components of the tumour micro‐environment. On activation by inflammatory cytokines, NF‐κB complexes are capable of promoting tumour cell survival through anti‐apoptotic signalling in prostate cancer (PCa). Positive feedback loops are able to maintain NF‐κB activation. NF‐κB activation is also associated with the metastatic phenotype and PCa progression to castration‐resistant prostate cancer (CRPC). A novel role for inhibitor of NF‐κB kinase (IKK)‐α in NF‐κB‐independent PCa progression to metastasis and CRPC has recently been uncovered, providing a new mechanistic link between inflammation and PCa. Expansion of PCa progenitors by IKK‐α may be involved in this process. In this review, we offer the latest evidence regarding the role of the NF‐κB pathway in PCa and discuss therapeutic attempts to target the NF‐κB pathways. We point out the need to further dissect inflammatory pathways in PCa in order to develop appropriate preventive measures and design novel therapeutic strategies.
       
  • Postoperative nomogram to predict cancer‐specific survival after
           radical nephroureterectomy in patients with localised and/or locally
           advanced upper tract urothelial carcinoma without metastasis
    • Abstract: Objective To propose and validate a nomogram to predict cancer‐specific survival (CSS) after radical nephroureterectomy (RNU) in patients with pT1–3/N0–x upper tract urothelial carcinoma (UTUC). Patients and Methods The international and the French national collaborative groups on UTUC pooled data from 3387 patients treated with RNU. Only 2233 chemotherapy naïve pT1–3/N0–x patients were included in the present study. The population was randomly split into the development cohort (1563) and the external validation cohort (670). To build the nomogram, logistic regressions were used for univariable and multivariable analyses. Different models were generated. The most accurate model was assessed using Harrell's concordance index and decision curve analysis (DCA). Internal validation was then performed by bootstrapping. Finally, the nomogram was calibrated and externally validated in the external dataset. Results Of the 1563 patients in the nomogram development cohort, 309 (19.7%) died during follow‐up from UTUC. The actuarial CSS probability at 5 years was 75.7% (95% confidence interval [CI] 73.2–78.6%). DCA revealed that the use of the best model was associated with benefit gains relative to prediction of CSS. The optimised nomogram included only six variables associated with CSS in multivariable analysis: age (P < 0.001), pT stage (P < 0.001), grade (P < 0.02), location (P < 0.001), architecture (P < 0.001) and lymphovascular invasion (P < 0.001). The accuracy of the nomogram was 0.81 (95% CI, 0.78–0.85). Limitations included the retrospective study design and the lack of a central pathological review. Conclusion An accurate postoperative nomogram was developed to predict CSS after RNU only in locally and/or locally advanced UTUC without metastasis, where the decision for adjuvant treatment is controversial but crucial for the oncological outcome.
       
  • Low‐dose oral desmopressin for treatment of nocturia and nocturnal
           enuresis in patients after radical cystectomy and orthotopic urinary
           diversion
    • Abstract: Objectives To assess the effect of oral desmopressin on nocturia and nocturnal enuresis in patients after orthotopic neobladder reconstruction. Patients and Methods Of 55 patients who underwent radical cystectomy and orthotopic neobladder reconstruction at our medical centre in the period 2004–2011, 34 patients were deemed eligible for the present study. Inclusion criteria were estimated glomerular filtration rate >50 mL/min/1.73 m2, normal baseline sodium serum level, intact daytime urinary continence, and any degree of nocturia or nocturnal enuresis. Patients were treated daily with oral desmopressin 0.1 mg at bedtime for 30 days and completed the Nocturia, Nocturnal Enuresis and Sleep Interruption Questionnaire at trial enrolment and closure. Sodium serum levels were monitored throughout. Results Three patients withdrew from the trial because of headaches or anxiety. The mean (sd) number of nocturnal voids decreased from 2.5 (1.4)/night at baseline to 1.5 (1.3)/night at trial closure (P = 0.015). The number of patients with one or no episodes of nocturnal enuresis per week increased from six to 12 (19 to 39%; P = 0.065). Thirteen patients (42%) reported an increase of a minimum 1–2 h of sleep until the first nocturnal void; all of them asked to continue the drug. No significant adverse events or changes in sodium level were observed. Conclusions Bedtime treatment with low‐dose oral desmopressin appears to decrease episodes of nocturia and nocturnal enuresis effectively and safely in ∼50% of the patients with neobladder, allowing longer undisrupted sleep time and improved quality of life. Further investigation is warranted to determine if higher doses would result in a more meaningful clinical response.
       
  • First round of targeted biopsies using magnetic resonance
           imaging/ultrasonography fusion compared with conventional transrectal
           ultrasonography‐guided biopsies for the diagnosis of localised
           prostate cancer
    • Abstract: Objectives To assess the accuracy of magnetic resonance imaging (MRI)/transrectal ultrasonography (TRUS) fusion to guide first‐round biopsies in the diagnosis of localised prostate cancer (PCa) in men with a prostate‐specific antigen (PSA) ≤10 ng/mL. Patients and Methods A prospective study was conducted on men who met the following criteria: first‐round biopsy, multiparametric MRI (mpMRI) showing a lesion with a Likert score ≥2 and a PSA
       
  • Predictors of preoperative delays before radical cystectomy for bladder
           cancer in Quebec, Canada: a population‐based study
    • Abstract: Objectives To characterise and measure different components of preoperative delays experienced by patients with bladder cancer before radical cystectomy (RC) in the province of Quebec, Canada and to identify the predictors of long waiting times. Methods We conducted a retrospective cohort study using the data of patients who underwent RC for bladder cancer between 2000 and 2009 in Quebec. The cohort was obtained with the linkage of two provincial health databases: the Régie de l'assurance maladie du Québec database (data on medical services dispensed to Quebec residents), and the Fichier des évenements démographiques de l’Institut de la statistique du Québec database (demographic data on births and deaths). For the entire cohort, we determined several components of delay from first medical visit related to bladder cancer symptoms until RC. Predictors of long delays were analysed using logistic regression. Results We analysed a total of 2778 patients who met the inclusion criteria. The median urologist referral delay was 32 days. The median delays between first urologist visit and RC and between transurethral resection of bladder tumour (TURBT) to RC were 90 days and 46 days, respectively. The median overall delay was 116 days. All components of delay progressively increased from the decade of the 1990s to the decade of the 2000s. Male gender was a protective factor for several components of delay, which suggests that gender‐related variations may exist in the course of care for bladder cancer (odds ratio 0.67, 95% CI 0.50–0.89 for overall delay). Patient age and gender were associated with delayed urologist referral, delayed time to TURBT, and long overall waiting time. Factors related to the health system were associated with long cystoscopy delays. Conclusion Median preoperative delays among patients with bladder cancer have been increasing and remain unacceptably long. Patient's age, gender and type of hospital facility were associated with long waiting times.
       
  • Prostate tumour volumes: evaluation of the agreement between magnetic
           resonance imaging and histology using novel co‐registration software
           
    • Abstract: Objective To evaluate the agreement between prostate tumour volume determined using multiparametric magnetic resonance imaging (MRI) and that determined by histological assessment, using detailed software‐assisted co‐registration. Materials and Methods A total of 37 patients who underwent 3T multiparametric MRI (T2‐weighted imaging [T2WI], diffusion‐weighted imaging [DWI]/apparent diffusion coefficient [ADC], dynamic contrast‐enhanced [DCE] imaging) were included. A radiologist traced the borders of suspicious lesions on T2WI and ADC and assigned a suspicion score of between 2 and 5, while a uropathologist traced the borders of tumours on histopathological photographs. Software was used to co‐register MRI and three‐dimensional digital reconstructions of radical prostatectomy specimens and to compute imaging and histopathological volumes. Agreement in volumes between MRI and histology was assessed using Bland–Altman plots and stratified by tumour characteristics. Results Among 50 tumours, the mean differences (95% limits of agreement) in MRI relative to histology were −32% (−128 to +65%) on T2WI and −47% (−143 to +49%) on ADC. For all tumour subsets, volume underestimation was more marked on ADC maps (mean difference ranging from −57 to −16%) than on T2WI (mean difference ranging from −45 to +2%). The 95% limits of agreement were wide for all comparisons, with the lower 95% limit ranging between −77 and −143% across assessments. Volume underestimation was more marked for tumours with a Gleason score ≥7 or a MRI suspicion score 4 or 5. Conclusion Volume estimates of prostate cancer using MRI tended to substantially underestimate histopathological volumes, with a wide variability in extent of underestimation across cases. These findings have implications for efforts to use MRI to guide risk assessment.
       
  • The Wallstent: long‐term follow‐up of metal stent placement
           for the treatment of benign ureteroileal anastomotic strictures after
           Bricker urinary diversion
    • Abstract: Objective To evaluate the long‐term follow‐up (primary and secondary patency) of metal stent placement in benign ureteroileal anastomotic strictures after Bricker urinary diversion and to compare the failed treatment group with the group of successfully treated patients to search for predisposing factors of stent failure. Patients and Methods For patients treated since 1989 for benign ureteroileal strictures after Bricker urinary diversion with end‐to‐side anastomosis, we retrospectively collected data on clinical history, stent placement, auxiliary measures and patency rates from a prospectively kept database. Results In all, 49 patients (mean age 64 years) underwent 56 metal stent procedures. Placement of the stent was possible in all patients. Stent patency without auxiliary treatment remained adequate in 23 cases (primary patency of 41.1%, mean follow‐up 37.7 months). A secondary treatment was successfully performed in 11 patients who had stent obstruction, mostly caused by hyperplastic reaction, encrustation, or migration of the stent. The secondary patency rate was 60.7% (mean follow‐up 55.8 months), comparable with patency rates of 36–100% described in literature with mostly small patient groups and much shorter follow‐up periods. Conclusion To the best of our knowledge we report the largest series of metal stenting in benign ureteroileal anastomotic strictures with the longest follow‐up. We show that placement of a metal stent can lead to a permanent de‐obstruction in approximately six out of 10 patients with preservation of renal function.
       
  • Critical analysis of phase II and III randomised control trials (RCTs)
           evaluating efficacy and tolerability of a β3‐adrenoceptor
           agonist (Mirabegron) for overactive bladder (OAB)
    • Abstract: To critically analyse available phase II and III randomised control trials (RCTs) reporting clinical data about the efficacy and tolerability of Mirabegron (a β3‐adrenoceptor agonist) in the treatment of overactive bladder (OAB) syndrome. A review of the literature was performed in September 2013 using the MEDLINE database. A ‘free text’ protocol was used for the search strategy using ‘overactive bladder’ and ‘Mirabegron’ as keywords. Subsequently, the searches were pooled and limited to phase II and III RCTs. Two phase II and five phase III RCTs were selected and analysed. The available phase II studies showed the efficacy and tolerability of different doses of Mirabegron compared with placebo. Moreover, a dose‐ranging study showed that 50 mg once daily should be considered the most promising dose for clinical use. The 12‐week phase III studies confirmed the effectiveness of Mirabegron to significantly reduce the mean number of incontinence episodes/24 h and the mean number of micturitions/24 h compared with placebo. A post hoc analysis confirmed that favourable results with Mirabegron were reported both in patients with OAB who were antimuscarinic naïve and in those who had discontinued prior antimuscarinic therapy. Moreover, a phase III trial showed the safety and tolerability of 12‐month treatment of Mirabegron. Discontinuation due to adverse events was low both using the 50 and 100 mg dose of Mirabegron. Mirabegron is the first of a new class of drugs for the treatment of OAB able to influence non‐voiding activity and produce an increased storage capacity and inter‐void interval. Recently published phase II and III RCTs have shown that the β3‐adrenoceptor‐selective agonist, Mirabegron, is an effective and safe drug for the symptomatic treatment of OAB syndrome. Mirabegron represents a valid medical option both for patients with OAB who are antimuscarinic naïve, as well as in those where antimuscarinics are ineffective or not tolerated.
       
  • Can factors affecting complication rates for ureteric
           re‐implantation be predicted' Use of the modified Clavien
           classification system in a paediatric population
    • Abstract: Objective To determine preoperative predictive factors of postoperative complications of ureteric re‐implantation in children by using the modified Clavien classification system (MCCS), which has been widely used for complication rating of surgical procedures. Patients and Methods In all, 383 children who underwent ureteric re‐implantation for vesico‐ureteric reflux (VUR) and obstructing megaureters between 2002 and 2011 were included in the study. Intravesical and extravesical ureteric re‐implantations were performed in 338 and 45 children, respectively. Complications were evaluated according to the MCCS. Univariate and multivariate analyses were used to determine predictive factors affecting complication rates. Results In all, 247 girls and 136 boys were studied. The mean (sd) age was 46 (25) months and the mean (sd) follow‐up was 49.4 (27.8) months. The mean (sd) hospitalisation time was 4.7 (1.6) days. Complications occurred in 76 (19.8%) children; 34 (8.9%) were MCCS grade I, 22 (5.7%) were grade II and 20 (5.2%) were grade III. Society of Fetal Urology (SFU) grade 3–4 hydronephrosis, obstructing megaureters, a tailoring‐tapering and folding procedure, refractory voiding dysfunction and a duplex system were statistically significant predictors of complications on univariate analysis. Prior injection history, paraureteric diverticula, stenting, gender, age, operation technique (intra vs extravesical) were not significant predictors of complications. In the multivariate analysis refractory voiding dysfunction, a tailoring‐tapering and folding procedure, obstructing megaureters (diameter of >9 mm) and a duplex system were statistically significant predictors of complications. Conclusion Ureteric re‐implantation remains a valid option for the treatment of certain patients with VUR. Refractory voiding dysfunction, a tailoring‐tapering and folding procedure, obstructing megaureters (diameter of >9 mm) and associated duplex systems were the main predictive factors for postoperative complications. Use of a standardised complication grading system, such as the MCCS, should be encouraged to allow the valid comparison of complication rates between series.
       
  • Balancing cardiovascular (CV) and cancer death among patients with small
           renal masses: modification by CV risk
    • Abstract: Objective To assess modification of comparative cancer survival by cardiovascular (CV) risk and treatment strategy among older patients with small renal masses (SRMs). Patients and Methods Patients with localised T1a renal cell carcinoma were identified in the Surveillance, Epidemiology and End Results‐Medicare database (1995–2007). Patients were stratified by CV risk, using major atherosclerotic CV comorbidities identified by the Framingham Heart Study, to compare overall (OS), cancer‐specific (CSS), and CV‐specific survival (CVSS) for those who deferred therapy (DT) to those undergoing either partial (PN) or radical nephrectomy (RN). Cox proportional hazards and Fine and Gray competing risks regression adjusted for demographics, comorbidities, and tumour size were performed. Results In all, 754 (10.5%) patients had DT, 1849 (25.8%) patients underwent PN, and 4574 (63.7%) patients underwent RN. Patients at high CV risk who had DT had the greatest CV‐to‐cancer mortality rate ratio (2.89), and CV risk was generally associated with worse OS and CVSS. Patients in the high CV risk strata had no difference in CSS between treatment strategies [DT vs PN: hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.25–1.41; DT vs RN: HR 0.81, 95%CI 0.46–1.43)], while there was a 2–4 fold CSS benefit for surgery in the low CV risk strata. Conclusions Cancer survival was comparable across treatment strategies for older patients with SRMs with high risk CV disease. Greater attention to CV comorbidity as it relates to competing risks of death and life expectancy may be deserved in selecting patients appropriate for active surveillance because patients at low CV risk might benefit from surgery.
       
  • Should we routinely stent after ureteropyeloscopy'
    • Abstract: Arguments ‘for’ and ‘against’ ureteric stenting after ureteropyeloscopy are discussed. An individualised approach balancing renal function preservation, irritative lower urinary tract symptoms and emergent return to theatre needs to be adopted while being mindful of healthcare spending.
       
  • Multidisciplinary urological engagement in translational renal cancer
           research
    •  
  • The impact of androgen‐deprivation therapy (ADT) on the risk of
           cardiovascular (CV) events in patients with non‐metastatic prostate
           cancer: a population‐based study
    • Abstract: Objective To examine and quantify the contemporary association between androgen‐deprivation therapy (ADT) and three separate endpoints: coronary artery disease (CAD), acute myocardial infarction (AMI), and sudden cardiac death (SCD), in a large USA contemporary cohort of patients with prostate cancer. Patients and Methods In all, 140 474 patients diagnosed with non‐metastatic prostate cancer between 1995 and 2009 within the Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database were abstracted. Patients treated with ADT and those not receiving ADT were matched using propensity score methodology. The 10‐year CAD, AMI, and SCD rates were estimated. Competing‐risks regression analyses tested the association between the type of ADT (GnRH agonists vs bilateral orchidectomy) and CAD, AMI, and SCD, after adjusting for the risk of dying during follow‐up. Results Overall, the 10‐year rates of CAD, AMI, and SCD were 25.9%, 15.6%, and 15.8%, respectively. After stratification according to ADT status (ADT‐naïve vs GnRH agonists vs bilateral orchidectomy), the CAD rates were 25.1% vs 26.9% vs 23.2%, the AMI rates were 14.8% vs 16.6% vs 14.8%, and the SCD rates were 14.2% vs 17.7% vs 16.4%, respectively. In competing‐risks multivariable regression analyses, the administration of GnRH agonists (all P < 0.001), but not bilateral orchidectomy (all P ≥ 0.7), was associated with higher risk of CAD, AMI, and SCD. Conclusions The administration of GnRH agonists, but not orchidectomy, is still associated with a significantly increased risk of CAD, AMI, and, especially, SCD in patients with non‐metastatic prostate cancer. Alternative forms of ADT should be considered in patients at higher risk of CV events.
       
  • Anxiety in the management of localised prostate cancer by active
           surveillance
    • Abstract: Objectives To describe a range of anxieties in men on active surveillance (AS) for prostate cancer and determine which of these anxieties predicted health‐related quality of life (HRQL). Patients and Methods In all, 260 men with prostate cancer on AS were invited to complete psychological measures including the Hospital and Anxiety Depression Scale; the State‐Trait Anxiety Inventory‐Trait Scale; the Memorial Anxiety Scale for Prostate Cancer; and the Functional Assessment of Cancer Therapy Scale‐Prostate. Overall, 86 men with a mean (sd, range) age of 65.7 (5.4, 51–75) years returned data, yielding a response rate of 33%. Outcome measures were standardised psychological measures. Pearson's correlations were used to examine bivariate relationships, while regression analyses were used to describe predictors of dependent variables. Results When compared with the findings of prior research, the men in our cohort had normal levels of general anxiety and illness‐specific anxiety and high prostate cancer‐related HRQL. Age, trait anxiety and fear of recurrence (FoR) were significant predictors of prostate cancer‐related HRQL; trait anxiety and FoR were significant predictors of total HRQL. Results should be interpreted in context of sample characteristics and the correlational design of the study. Conclusions Participants reported low levels of anxiety and high HRQL. Trait anxiety and FoR were significant predictors of both prostate cancer‐related and total HRQL. The administration of a short trait‐anxiety screening tool may help identify men with clinically significant levels of anxiety and those at risk of reduced HRQL.
       
  • A Valsalva leak‐point pressure of >100 cmH2O is associated
           with greater success in AdVance™ sling placement for the treatment
           of post‐prostatectomy urinary incontinence
    • Abstract: Objectives To determine if there is a Valsalva leak‐point pressure (VLPP) threshold that predicts for retro‐urethral transobturator sling (RTS) success in men with post‐prostatectomy urinary incontinence (UI). Patients and Methods The preoperative urodynamic parameters of all patients undergoing RTS (AdVance™) sling surgery over the last 5 years were analysed and compared with the postoperative outcomes. The sling was defined as having been successful if the patient no longer had to wear pads or merely used a pad to provide a sense of security. Results In all, 46 men with a mean (range) age of 65 (45–83) years, underwent AdVance™ sling surgery. 10 men had undergone holmium laser enucleation of the prostate, one a transurethral resection of the prostate and 35 radical prostatectomy. 11 men had a VLPP of ≤100 cmH2O. Of these 11 men, three had no, or minimal, improvement in their leakage and all three required a secondary procedure (artificial urinary sphincter, AUS). In the 35 men with a VLPP of >100cmH2O there were three failures. One of these was successfully salvaged with a repeat sling, another with an AUS and one with ProACT™ balloons. The hazard ratio (HR) for failure with a VLPP of ≤100 cmH20 compared with a VLPP of >100 cmH2O was 4 (95% confidence interval 0.68–23.7). Conclusion A VLPP of >100 cmH2O has a high degree of predictability for success for AdVance™ sling placement for men with post‐prostatectomy UI.
       
  • Trans‐perineal prostate biopsy: template‐guided or
           free‐hand''
    • Abstract: There is growing interest in the use of trans‐perineal template biopsy for the diagnosis of prostate cancer. This is principally due to the reduced sepsis rate and improved diagnostic accuracy when compared with transrectal prostate biopsy. However, the need for a brachytherapy stepper and template are limiting factors. Here we discuss trans‐perineal biopsy using a free‐hand approach.
       
  • Medium‐term oncologic outcomes for extended versus saturation biopsy
           and transrectal versus transperineal biopsy in active surveillance for
           prostate cancer
    • Abstract: Purpose • In AS for low risk PCa, we assessed whether saturation or transperineal biopsy altered medium‐term oncologic outcomes compared with standard transrectal biopsy. Materials and methods • Retrospective analysis of prospectively collected data from two cohorts with localised PCa (1998‐2012) undergoing AS. • PCa‐specific, metastasis‐free and treatment‐free survival, unfavourable disease and significant cancer at RP were compared for standard (6‐12 core, median 10) versus saturation (>12 core, median 16), and transrectal versus transperineal biopsy, using multivariate analysis. Results • 650 men analysed; Median (mean) follow‐up of 55 (67) months. • PCa‐specific, metastasis‐free and BCR‐free survival were 100%, 100% and 99% respectively. Radical treatment‐free survival at 5 and 10 years were 57% and 45% respectively (median time to treatment 7.5 years). • On KM analysis, saturation biopsy was associated with increased objective biopsy progression requiring treatment (Log Rank x2=5.87, p=0.01). On multivariate PH analysis, saturation biopsy (HR=1.68, p
       
  • Co‐administration of TRPV4 and TRPV1 antagonists potentiate the
           effect of each drug in a rat model of cystitis
    • Abstract: Objective To investigate TRPV4 expression in bladder afferents. To study the effect of TRPV4 and TRPV1 antagonists, alone and in combination, in bladder hyperactivity and pain induced by cystitis. Material and Methods TRPV4 expression in bladder afferents was analyzed by immunohistochemistry in L6 dorsal root ganglia (DRG), labelled by fluorogold injected in the urinary bladder. TRPV4 and TRPV1 co‐expression was also investigated in L6 DRG neurons of control and in animals with lipopolysaccharide‐induced cystitis. The effect of TRPV4 antagonist RN1734 and TRPV1 antagonist SB366791 on bladder hyperactivity and pain induced by cystitis was assessed by cystometry and visceral pain behaviour tests, respectively. Results TRPV4 is expressed in sensory neurons that innervate the urinary bladder. TRPV4 positive bladder afferents represent a different population than the TRPV1 expressing bladder afferents, since their co‐localization was minimal in control and inflamed animals. While low doses of RN1734 and SB366791 (176.7 ng/kg and 143.9 ng/kg, respectively) had no effect on bladder activity, the co‐administration of the two totally reversed bladder hyperactivity induced by lipopolysaccharide. In these same doses, the antagonists partially reversed bladder pain behaviour induced by cystitis. Conclusions TRPV4 and TRPV1 are present in different bladder afferent populations. The synergistic activity of antagonists for these receptors in very low doses may offer the opportunity to treat lower urinary tract symptoms while minimizing the potential side‐effects of each drug.
       
  • The diagnostic accuracy of MRI PI‐RADS scoring in a transperineal
           prostate biopsy setting
    • Abstract: Objectives ● To determine the sensitivity, specificity of multiparametric MRI (mp‐MRI) for significant prostate cancer with transperineal sector biopsy (TPB) as the reference standard. Patients and Methods ● Consecutive men who presented for TPSB between July 2012 and November 2013 following mp‐MRI (T2 and diffusion‐weighted images, 1.5 Tesla scanner, 8‐channel body coil) were included. ● A specialist uro‐radiologist, blinded to clinical details, assigned qualitative PI‐RADS (Prostate Imaging Reporting and Data System) scores on a Likert scale of 1 to 5 denoting the likelihood of significant prostate cancer with 1‐highly unlikely, 3‐equivocal, and 5‐highly likely. ● Transperineal sector biopsies sampled 24‐40 cores (depending on prostate size) per patient. ● Significant prostate cancer was defined as the presence of Gleason pattern 4 or cancer core length ≥6mm.    Results ● Two hundred and one patients went on to analysis. Indications were: prior negative transrectal biopsy with continued suspicion of prostate cancer (103); primary biopsy (83); and active surveillance (15). Mean(±sd) age, PSA and prostate volumes were 65(±7) years, 12.8(±12.4)ng/mL and 62(±36)cm3 respectively. ● Overall, biopsies were benign, clinically insignificant and clinically significant in 124(62%), 20(10%) and 57(28%) men respectively. 2 of 88 men with PI‐RADS score 1 or 2 had significant prostate cancer giving sensitivity (95% confidence intervals) 97%(87 to 99) and specificity 60%(51 to 68) at this threshold. ● ROC analysis gave an area under the curve (95% confidence intervals) of 0.89 (0.82 to 0.92). ● The negative predictive value of a PI‐RADS score of ≤2 for clinically significant prostate cancer was 97.7% Conclusion ● PI‐RADS scoring performs well as a predictor for biopsy outcome and may be used in the decision making process for prostate biopsy.
       
  • Contemporary practice and technique related outcomes for radical
           prostatectomy in the United Kingdom: a report of national outcomes
    • Abstract: Objective • To determine current radical prostatectomy (RP) practice in the UK and compare surgical outcomes between techniques. Patients and methods • All RPs performed between 01 January 2011 and 31 December 2011 in the UK with data entered into the BAUS database were identified for analysis. • Overall surgical outcomes were assessed and subgroup analysis of these outcomes, based on operative technique (open, laparoscopic and robot assisted laparoscopic), were made. • Continuous variables were compared using the Mann‐Whitney U Test and categorical variables using the Pearson Chi‐squared test. Univariate and multivariate binary regression analyses were performed to assess the effect of patient, surgeon and technique related variables on surgical outcomes. Results • During the study period 2163 radical prostatectomies were performed by 115 consultants with a median of 11 (1‐154) cases per consultant. Most RPs were performed laparoscopically (ORP 25.8%, LRP 54.6%, RALP 19.6%) and those performing minimally invasive techniques are more likely to have a higher annual case volume with 50cases/year. • The majority of cases were classified as intermediate or high risk disease pre‐operatively (1596 cases [82.5%]) and this increased to 97.2% (1649 patients) on post‐operative risk stratification. • Overall intra‐operative complication rate was 14.2% and was significantly greater in LRP (17.8%) compared to the ORP (8.2%) and RALP (12.4%), p500ml, >1000ml and >2000ml EBL compared to other techniques (p
       
  • Argument for prostate cancer screening in populations of
           African‐Caribbean origin
    • Abstract: The high prevalence, incidence and mortality rates of prostate cancer in Tobago would appear to strongly indicate that screening of this population would be justified and could positively impact on mortality. We consider our approach to be consonant with the recommendations of the EAU (Heidenreich A et al, 2013) and the findings of Hugosson et al, 2014)
       
  • Ejaculatory Dysfunction After Treatment for Lower Urinary Tract Symptoms:
           Retrograde Ejaculation or Retrograde Thinking'
    •  
  • Cytotoxic chemotherapy in the contemporary management of metastatic
           prostate cancer
    • Abstract: For several years, docetaxel was the only treatment shown to improve survival of patients with metastatic castration‐resistant prostate cancer (mCRPC). There are now several novel agents available, although chemotherapy with docetaxel and cabazitaxel continues to play an important role. However, the increasing number of available agents will inevitably affect the timing of chemotherapy and therefore it may be important to offer this approach before declining performance status renders patients ineligible for chemotherapy. Patient selection is also important to optimize treatment benefit. The role of predictive biomarkers has assumed greater importance due to the development of multiple agents and resistance to available agents. In addition, the optimal sequence of treatments remains undefined and requires further study in order to maximize long‐term outcomes. We provide an overview of the clinical data supporting the role of chemotherapy in the treatment of mCRPC and the emerging role in metastatic castration‐sensitive prostate cancer. We review the key issues in the management of patients including selection of patients for chemotherapy, when to start chemotherapy, and how best to sequence treatments to maximize outcomes. In addition, we briefly summarize the promising new chemotherapeutic agents in development in the context of emerging therapies.
       
  • The effect of hypogonadism and testosterone‐enhancing therapy on
           alkaline phosphatase and bone mineral density
    • Abstract: Objective To evaluate the relationship of testosterone (T) enhancing therapy on alkaline phosphatase (AP) in relation to bone mineral density (BMD) in hypogonadal men. Patients and Methods Retrospective review of 140 men with T
       
  • Comparison of MR‐US fusion‐guided prostate biopsies obtained
           from axial and sagittal approaches
    • Abstract: Objectives  •To compare cancer detection rates and concordance between MR‐US fusion‐guided prostate biopsy cores obtained from axial and sagittal approaches. Patients and Methods  •Institutional records of MR‐US fusion‐guided biopsy were reviewed.  •Detection rates for all cancers, Gleason ≥3+4 cancers, and Gleason ≥4+3 cancers were computed.  •Agreement between axial and sagittal cores for cancer detection, and frequency where one upgraded the other was computed on a per‐target and per‐patient basis. Results  •893 encounters from 791 subjects that underwent MR‐US fusion‐guided biopsy in 2007–2013 were reviewed, yielding 4688 biopsy cores from 2344 targets for analysis.  •Mean age and PSA at each encounter was 61.8 years and 9.7ng/ml (median=6.45ng/ml).  •Detection rates for all cancers, ≥3+4 cancers, and ≥4+3 cancers were 25.9%, 17.2%, and 8.1% for axial cores, and 26.1%, 17.6%, and 8.6% for sagittal cores.  •Per‐target agreement was 88.6%, 93.0%, and 96.5% respectively. On a per‐target basis, the rates at which one core upgraded or detected a cancer missed on the other were 8.3% and 8.6% for axial and sagittal cores respectively.  •Even with the inclusion of systematic biopsies, omission of axial or sagittal cores would have resulted in missed detection or under‐characterization of cancer in 4.7% or 5.2% of patients respectively. Conclusion  •Cancer detection rates, Gleason scores, and core involvement from axial and sagittal cores are similar, but significant cancer may be missed if only one core is obtained for each target.  •Discordance between axial and sagittal cores is greatest in intermediate‐risk scenarios, where obtaining multiple cores may improve tissue characterization.
       
  • Transrectal Ultrasound Guided Pelvic Plexus Block to reduce pain during
           prostate biopsy: a randomized controlled trial
    • Abstract: Objective To assess the role of pelvic plexus block (PPB) in reducing pain during transrectal ultrasound (TRUS) guided prostate biopsy, in comparison with the conventional periprostatic nerve block (PNB). Materials and Methods A prospective, double blinded observational study was conducted with the patients being randomized into three groups. Group‐1 (47 patients) received intrarectal local anaesthesia (IRLA) with 10 ml of 2% lignocaine jelly along with pelvic plexus block (PPB) with 2.5 ml of 2% lignocaine injection bilaterally. Group‐2 (46 patients) received IRLA with periprostatic nerve block (PNB). Group‐3 (46 patients) received only IRLA without any type of nerve block. The patients were requested to rate the level of pain from 0 to 10 on visual analogue scale (VAS) at two time points ‐ VAS‐1: during biopsy procedure and VAS ‐2: 30 minutes after the procedure. Results Mean age of the patients, mean volume of the prostates and mean serum PSA values were comparable among these three groups. The mean pain score during the biopsy was significantly less in PPB group (mean score of 2.91, range 2‐4), compared to PNB group (mean score of 4, range 3‐5), and both these groups were superior to no nerve block group (mean score of 5.4, range 3‐7). There was no significant difference between the mean pain scores, 30 minutes after the procedure, among the three groups with the mean score being 2.75 (range 2‐4), 2.83 (range 2‐4) and 2.85 (range 2‐4), respectively. Conclusion Pelvic plexus block (PPB) is superior to conventional periprostatic nerve block (PNB) in term of pain control during TRUS biopsy and both are in turn superior to no nerve block.
       
  • USANZ: The ‘Timing of androgen deprivation therapy in incurable
           prostate cancer’ protocol (TOAD) – where are we now'
           Synopsis of the Victorian Cooperative Oncology Group PR 01‐03 and
           TransTasman Radiation Oncology Group 03.06 clinical trial
    • Abstract: Objectives To outline the development of the TOAD (Timing of Androgen Deprivation) protocol, a collaborative randomised clinical trial under the auspices of the Cancer Council Victoria, the Trans Tasman Radiation Oncology Group, and the Urological Society of Australia and New Zealand, which opened to recruitment in 2004 Patients and Methods The principal hypothesis for the trial was that the early introduction of ADT (experimental arm) at the time when curative therapies are no longer considered an option, would improve overall survival for these patients, whilst maintaining an acceptable quality of life; compared to waiting for disease progression or the development of symptoms (control arm). An increase in overall survival at five years of 10% was judged to be clinically worthwhile. Results Recruitment was slow, with fewer than half of the protocol requirement of 750 patients eventually accrued, but nonetheless it is considered that the trial will still contribute a major source of evidence in this area. The study closed to follow‐up at the end of 2013, with data analysis commencing mid‐2014, and with the primary publication anticipated to be submitted by the end of 2014. Conclusions The question of timing of androgen deprivation still remains relevant in the current era of newer and more varied treatment modalities. Even with the advent of novel chemotherapy and the biological agents which are undergoing investigation for progressively earlier disease stages, the dilemma of when to commence palliative treatment in an asymptomatic patient will remain, unless or until these agents are shown to increase overall survival. The TOAD trial will contribute to answering at least in part, some of these questions.
       
  • Upper Limit of Cancer Extent on Biopsy Defining Very Low Risk Prostate
           Cancer
    • Abstract: Objective To investigate how much Gleason pattern 3 cancer the prostate biopsy specimens may contain without an increased risk of undetected more aggressive cancer, compared with the risk for cancers fulfilling the National Comprehensive Cancer Network (NCCN) criteria for very low risk prostate cancer. Subjects and Methods We identified 1,286 men aged < 70 years in the National Prostate Cancer Register of Sweden who underwent primary radical prostatectomy for stage T1c or T2 prostate cancer with Gleason pattern ≤ 3 only, prostate‐specific antigen < 10 ng/mL and PSA density < 0.15 ng/ml/cc. The association between the extent of cancer in the biopsies (the number and proportion of positive cores and the total cancer length in the cores in mm) and the likelihood of Gleason pattern 4‐5 in the prostatectomy specimen was analysed with logistic regression. Results Overall, 438 (34%) of the 1,286 men had Gleason pattern 4‐5 in the prostatectomy specimen. Increasing number and proportion of positive biopsy cores as well as increasing biopsy cancer length were both significantly associated with increased risk of upgrading at radical prostatectomy in univariable analysis, but in multivariable analysis only biopsy cancer length remained significant. The 684 men with stage T1c and < 8 mm cancer had similar risk of upgrading regardless of whether the number of positive biopsy cores was 1‐2 or 3‐4 (28% versus 27% risk); upgrading was more common among the remaining men (40%, p < 0.01). Conclusions Men younger than 70 years with stage T1c prostate cancer and 3‐4 biopsy cores with Gleason pattern 3 are not more likely to have undetected Gleason pattern 4‐5 cancer than men with 1‐2 cores with cancer, provided that the total biopsy cancer length is < 8 mm. We propose that the definition of very low risk prostate cancer is widened accordingly.
       
  • Transient receptor potential channel modulators as pharmacological
           treatments for lower urinary tract symptoms: myth or reality'
    • Abstract: Transient Receptor Potential (TRP) channels belong to the most intensely pursued drug targets of the last decade. These ion channels are considered promising targets for the treatment of pain, hypersensitivity disorders and lower urinary tract symptoms (LUTS). The aim of this review is to discuss to which extent TRP channels have lived up to their promise as new pharmacological targets in the lower urinary tract and to outline the challenges that lie ahead. TRPV1 agonists have proven their efficacy in the treatment of neurogenic detrusor overactivity albeit at the expense of prolonged adverse effects as pelvic burning pain, sensory urgency, and hematuria. TRPV1 antagonists have been very successful in preclinical studies to treat pain and detrusor overactivity. However, clinical trials with the first generation TRPV1 antagonists were terminated early due to hyperthermia, a serious, on‐target, side effect. TRPV4, TRPA1 and TRPM8 have important sensory functions in the lower urinary tract. Antagonists of these channels have shown their potential in pre‐clinical studies of lower urinary tract dysfunction and are awaiting clinical validation.
       
  • Full immersion simulation – validation of a distributed simulation
           environment for technical and non‐technical skills training in
           urology
    • Abstract: Objectives To evaluate the face, content and construct validity of the Distributed Simulation (DS) environment for non‐technical skills training and for endourology technical skills training. To evaluate the educational impact of DS for urology training. Subjects and Methods Distributed Simulation offers a portable, low cost simulated operating room environment (OR) that can be set up in any open space. A prospective mixed methods design using established validation methodology was conducted in this simulated environment with ten experienced and ten trainee urologists. All participants performed a simulated prostate resection in the DS environment. Outcome measures included surveys to evaluate the DS, as well as comparative analyses of experienced and trainee urologist's performance using real time and blinded video analysis and validated performance metrics. Non‐parametric statistical methods were used to compare differences between groups. Results The DS environment demonstrated face, content and construct validity for both non‐technical and technical skills. Kirkpatrick level 1 evidence for the educational impact of the DS environment was demonstrated. Further studies are needed to evaluate the effect of simulated OR training on real OR performance. Conclusions This study has demonstrated the validity of the DS environment for non‐technical, as well as technical skills training. DS‐based simulation appears to be a valuable addition to traditional classroom based simulation training.
       
  • The changing reality of urothelial bladder cancer: should
           non‐squamous variant histology be managed as a distinct clinical
           entity'
    • Abstract: Objectives To assess the effect of non‐squamous variant histology on survival in muscle invasive urothelial bladder cancer. Materials and Methods A cohort of 411 radical cystectomy cases performed with curative intent for muscle invasive primary urothelial carcinoma (UC) was identified between 2008 and June 2013. Survival analysis was evaluated using Kaplan‐Meier methodology comparing NV+SQD histology to non‐SQD variant histology (non‐SQD variants). Multivariable cox proportional hazards regression assessed all‐cause and disease specific mortality. Results Of the 411 cystectomy cases, 77 (19%) were non‐SQD variant histology. Median OS for non‐SQD variant histology was 28 months, whereas the NV+SQD group had not reached median OS at 74 months (log rank test p
       
  • The treatment of Penile Carcinoma‐In‐Situ within a UK
           supra‐regional network
    • Abstract: Objectives To review outcomes of the treatment of carcinoma in situ of the penis at a large supra‐regional penile cancer network, where centralisation has permitted greater experience with treatment outcomes, and suggest treatment strategies. Materials and Methods The network penile cancer database which details presentation, treatment and complications was analysed from 2003‐10, identifying patients with CIS, with minimum follow up of 2 years, looking at treatments administered and outcomes. Results Fifty‐seven patients with mean age 61yr (range:34‐91yr) were identified. Eighteen were treated by circumcision (CIRC) only, 20 by CIRC and local excision (LE) and 19 by CIRC and 5‐flurouracil (5FU). Mean follow up was 3.5yr (2‐8). Of those treated by CIRC none subsequently developed CIS on the glans. For those who underwent CIRC+LE, 5/20 developed recurrence requiring further treatment. Of those treated by CIRC+5FU, 14/19 (73.7%) completely responded (CR). Of incomplete responders (IR, n=5), 2 showed focal invasive malignancy at repeat biopsy. One IR underwent glansectomy and 4 grafting. No CR relapsed. Complications of 5FU included significant inflammatory response in 7 (36.8%), with 2 requiring hospital admission and 1 neo‐phimosis (5.3%). Conclusion This study suggests that patients undergoing circumcision for isolated CIS and complete responders to 5FU may require only short term follow up, as recurrence is unlikely, whereas longer follow up is required for all other patients. However numbers in this study are small and larger studies are needed to support this. Incomplete response to 5FU dictates immediate re‐biopsy as it carries a significant chance of previously undetected invasive disease.
       
  • Disease‐specific death and metastasis do not occur in patients with
           Gleason score ≤6 on radical prostatectomy
    • Abstract: Objectives To assess the lymph node metastasis‐free survival, distant metastasis‐free survival and disease‐specific survival in men with Gleason score ≤6 prostate cancer on radical prostatectomy. Patients and methods We included 1101 consecutive radical prostatectomy patients operated between March 1985 to July 2013 at a single institution. The outcome variables were metastasis‐free survival and disease‐specific survival. The postoperative survival was estimated by the Kaplan‐Meier method. Results The Gleason score distribution of the study population (n=1101) was Gleason score ≤6 (n=449, 41%), Gleason score 3+4=7 (n=436, 40%), Gleason score 4+3=7 (n=99, 9%) and Gleason score 8‐10 (n=117, 11%). The median post‐operative follow‐up was 100 months (IQR 48‐150). During follow‐up 197 men (18%) died of whom 42 (3.8%) from prostate cancer related causes. A total of 19/1101 patients (1.7%) had documented lymph node metastasis at time of operation: 0 in Gleason score ≤6, 7 in Gleason score 3+4=7 (1.6%), 6 in Gleason score 4+3=7 (6.1%) and 6 in Gleason score 8‐10 (5.1%). Distant metastasis occurred in 56/1101 patients (5.1%): 0 in Gleason score ≤6, 23 in Gleason score 3+4=7 (5.3%), 17 in Gleason score 4+3=7 (17%) and 16 in Gleason score 8‐10 (14%). Disease‐specific death, stratified per Gleason score group was: 0 in ≤6, 16 (3.7%) in 3+4=7, 16 (16%) in 4+3=7 and 10 (8.5%) in 8‐10. Conclusion No metastasis or disease‐specific death were observed in men with Gleason score ≤6 prostate cancer on radical prostatectomy, demonstrating the negligible potential to metastasize in this large subgroup of prostate cancer patients.
       
  • Does cumulative prostate cancer length in prostate biopsies improve
           prediction of clinically insignificant cancer at radical prostatectomy in
           patients eligible for active surveillance'
    • Abstract: Objectives To evaluate if cumulative cancer length on prostate needle biopsy (Bx) divided by the number of biopsy cores (CCL/core) could improve prediction of insignificant cancer (IC) on radical prostatectomy (RP) in patients with prostate cancer (PCA) eligible for active surveillance (AS). Materials and Methods Patients diagnosed with PCA on extended (≥10 cores) Bx with initial prostate‐specific antigen (iPSA)
       
  • Partial Nephrectomy for the Treatment of Renal Cell Carcinoma and the Risk
           of End Stage Renal Disease
    • Abstract: Objective To assess whether radical nephrectomy (RN) compared to partial nephrectomy (PN) for the treatment of renal cell carcinoma (RCC) is associated with greater risk of end‐stage renal disease (ESRD). Subjects and Methods We performed a population‐based, retrospective cohort study using linked administrative databases in the province of Ontario, Canada. We included individuals with pathologically confirmed RCC diagnosed between 1995 and 2010. Cox proportional hazards (PH), propensity score, and competing risks models were used to assess the impact of treatment choice. The primary outcome was ESRD. Secondary outcomes included overall mortality, myocardial infarction, and new‐onset CKD. A modern cohort of patients (2003‐2010) was analyzed separately. Results We included a total of 11,937 patients, of whom 2,107 (18%) underwent PN. Median follow‐up was 57 months. In the full cohort, type of surgery was not associated with the rate of ESRD, whereas PN was associated with a decreased likelihood of ESRD compared to RN in the modern cohort using a multivariable PH model (HR 0.44, CI 0.25‐0.75) or propensity score modeling (HR 0.48, 0.27‐0.82). PN was also associated with a lower risk of new‐onset CKD (HR 0.48, CI 0.41‐0.57). Conclusions Although it is well‐known that RN is associated with more CKD than PN, we provide the first direct evidence that PN is associated with less ESRD requiring renal replacement therapy than RN in a modern cohort of patients with RCC.
       
 
 
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