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Journal Cover BJU International
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   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  [1597 journals]
  • Chromogranin A and neuron‐specific enolase serum levels as
           predictors of treatment outcome in metastatic castration‐resistant
           prostate cancer patients under abiraterone therapy
    • Abstract: Objective To determine the impact of elevated neuroendocrine serum markers on treatment outcome in patients with metastatic castration‐resistant prostate cancer (mCRPC) undergoing treatment with abiraterone in a post‐chemotherapy setting. Patients and Methods Chromogranin A (CGa) and neuron‐specific enolase (NSE) were determined in serum drawn before treatment with abiraterone of 45 mCRPC patients. Outcome measures were overall survival (OS), prostate‐specific antigen (PSA) response defined by PSA decline ≥50%, PSA progression‐free survival (PSA‐PFS) and clinical or radiographic PFS. Results CGa and NSE serum levels did not correlate (p=0.6). Patients were stratified in a low (n=9), intermediate (n=18) or high (n=18) risk group according to elevation of none, one or both neuroendocrine markers. Risk groups correlated with decreasing median OS (median OS not reached vs. 15.3 vs. 6.6 months; p
      PubDate: 2016-03-31T09:45:47.016166-05:
      DOI: 10.1111/bju.13493
  • Interpretation of conventional survival analysis and competing risk
           analysis: An example of hypertension and prostate cancer
    • Abstract: Most clinical studies use conventional methods for survival analysis and calculate the risk of the event of interest, however, it is important to understand that the study population is also at risk of competing events, for example death from other causes. Moreover, the risk of competing events may be dependent on the participants’ characteristics. Whether competing risks are taken into account or not, is of major importance when interpreting study results.Here, we use a practical example to elucidate the interpretational differences of absolute risk estimates obtained with both conventional methods for survival analysis and competing risk analysis. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-31T09:45:31.154284-05:
      DOI: 10.1111/bju.13494
  • Guidelines of Guidelines: Thromboprophylaxis for Urologic Surgery
    • Authors: Philippe D. Violette; Rufus Cartwright, Matthias Briel, Kari A.O. Tikkinen, Gordon H. Guyatt
      Abstract: The risks and benefits of thromboprophylaxis for urologic surgery depend on both patient specific and procedure specific factors [1,2]. Clinicians and patients must trade off a reduction in venous thromboembolism (VTE) against a potential increase in bleeding. Although investigators have not addressed the issue specifically for urological procedures, high quality evidence from randomized trials has demonstrated that pharmacological prophylaxis, with for example low molecular weight heparins (LMWH), decreases the risk of VTE in patients having abdominal or pelvic surgery by approximately 50% [1]. Best estimates for LMWH also suggest, however, an increase in the risk of post‐operative major bleeding by approximately 50% [1]. Although these relative risks are likely to be somewhat consistent across patients and procedures, the balance of benefits and harms varies with the absolute risk of VTE and bleeding. In patients with a high risk of VTE and a low risk of major bleeding, a 50% reduction in VTE represents a substantial benefit (for instance, from a baseline risk of 12% to 6%) and a 50% increase in bleeding represents a minimal increase in harm (for instance, from 0.2% to 0.3%). Patients whose risk of VTE without anticoagulation is low and whose bleeding risk is high face an opposite situation. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-31T09:31:56.923376-05:
      DOI: 10.1111/bju.13496
  • Change in Platelet Count as a Prognostic Indicator for Response to Primary
           Tyrosine Kinase Inhibitor Therapy in Metastatic Renal Cell Carcinoma
    • Authors: Zachary Hamilton; Hak J. Lee, Juan Himenez, Brian R. Lane, Song Wang, Alp T. Beksac, Kyle Gillis, Amy Alagh, Conrad Tobert, J. Michael Randall, Christopher J. Kane, Frederick Millard, Steven C. Campbell, Ithaar H. Derweesh
      Abstract: Objective To evaluate change in platelet count (ΔPlt) as an indicator of response to primary tyrosine kinase inhibitor (TKI) therapy for metastatic renal cell carcinoma (mRCC). Patients and Methods Multi‐center retrospective analysis of mRCC patients undergoing primary TKI from 5/2005‐8/2014. ΔPlt was defined as post‐treatment platelet count after first cycle minus pre‐treatment platelet count. RECIST criteria were used to define partial response (PR), stable disease (SD), and progressive disease (PD). Analysis was conducted between subgroups with stable/increased (+ΔPlt) and decreased (‐ΔPlt) counts. Primary outcome was overall survival (OS) by Kaplan‐Meier analysis. Multivariable analysis (MVA) was conducted for risk factors associated with PD. Results 115 mRCC patients were analyzed, +ΔPlt 19 (16.6%) and –ΔPlt 96 (83%). More patients with +ΔPlt had Karnofsky score 2 metastases (78.9% vs. 51%, p=0.041). More patients with +ΔPlt had PD (89.4% vs. –ΔPlt 19.1%, p
      PubDate: 2016-03-24T05:00:31.954762-05:
      DOI: 10.1111/bju.13490
  • Role of oral PentosanPolysulphate in reduction of local side effects of
           BCG in Non muscle invasive Bladder Cancer patients: a pilot study
    • Authors: Suresh Yadav; Vinay Tomar, Sher Singh Yadav, Shivam Priyadarshi, Indraneel Banerjee
      Abstract: Objective Intravesical immunotherapy with Bacillus Calmette–Guerin (BCG) is indicated for the treatment of high grade Ta/T1 non‐muscle invasive bladder cancer (NMIBC); but it is associated with significant local side effects. Aim of the study was to assess the role of oral Pentosan Polysulphate (PPS) in reduction of BCG related local side‐effects. Methods 32 symptomatic patients after BCG instillation were randomized into three groups: A, B and C. Group A received placebo (vitamin B complex tablet) in t.i.d dose, Group B received PPS 100 mg t.i.d. dose and Group C received PPS 100mg o.d and placebo (vitamin B complex tablet b.i.d dose) for 6 weeks. Visual Analog Scale (VAS) for bladder pain, Overactive Bladder‐Validated 8 Question Screener (OAB‐V8) and dysuria were evaluated in three groups before and during each weekly visit of BCG instillation. Results Post treatment mean VAS score was significantly lower in Group B (4.4±1.2) and C (5.8±0.8) as compared to group A (8±0.4).Also, the post treatment VAS score was significantly lower in group B v/s group C(p
      PubDate: 2016-03-24T04:55:30.54586-05:0
      DOI: 10.1111/bju.13489
  • Independent Surgical Validation of the New Prostate Cancer Grade Grouping
    • Authors: Daniel E. Spratt; Adam I. Cole, Ganesh S. Palapattu, Alon Z. Weizer, William C. Jackson, Jeffrey S. Montgomery, Robert Dess, Shuang G. Zhao, Jae Y. Lee, Angela Wu, Lakshmi P. Kunju, Emily Talmich, David C. Miller, Brent K. Hollenbeck, Scott A. Tomlins, Felix Y. Feng, Rohit Mehra, Todd M. Morgan
      Abstract: Objective To report the independent prognostic impact of the new prostate cancer grade grouping system in a large external validation cohort of patients treated with radical prostatectomy. Subjects/patients Between 1994 and 2013, 3,694 consecutive men were treated by radical prostatectomy at a single institution. To investigate the performance of and validate the grade‐grouping system, biochemical recurrence‐free survival (bRFS) rates were assessed using Kaplan Meier tests, Cox‐regression modeling, and discriminatory comparison analyses. Separate analyses were performed based on biopsy and prostatectomy grade. Results Median follow‐up was 52.7 months. The 5‐year actuarial bRFS for biopsy grade‐groups 1‐5 were 94.2%, 89.2%, 73.1%, 63.1%, and 54.7%, respectively (p
      PubDate: 2016-03-24T04:25:30.657129-05:
      DOI: 10.1111/bju.13488
  • Steroid co‐introduction with docetaxel chemotherapy for metastatic
           castration‐resistant prostate cancer affects PSA flare
    • Abstract: Objective To investigate the potential relationship of steroid usage with prostate‐specific antigen (PSA) flare and the prognostic impact of PSA flare, which is known to occur in 10–20% of patients with metastatic castration‐resistant prostate cancer during docetaxel chemotherapy. Patients and Methods This study included 71 patients with metastatic castration‐resistant prostate cancer treated by docetaxel chemotherapy with co‐introduction of steroid. PSA flare was defined as transient PSA increase followed by PSA decrease. Results PSA flare was recognized in 7.0–23.9% of patients according to various definitions. Intriguingly, men with steroid intake before the initiation of docetaxel chemotherapy experienced significantly fewer PSA flares. The progression‐free survival rate in men with PSA flare was equivalent to that of PSA responders, but significantly better than men with PSA failure. Conclusions Our results suggest that de novo steroid co‐introduction with docetaxel chemotherapy induce the PSA flare phenomenon. This novel finding may account for the mechanism of PSA flare as well as being valuable for distinguishing PSA elevation as PSA flare or failure. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-17T22:35:58.589837-05:
      DOI: 10.1111/bju.13483
  • ATRIGEL® polymer‐delivered subcutaneous leuprolide acetate
           formulations achieve and maintain castrate levels of testosterone in four
           open label studies in advanced prostate cancer patients
    • Authors: Neal D. Shore; Franklin Chu, Judd Moul, Daniel Saltzstein, Raoul Concepcion, John A. McLane, Stuart Atkinson, Alex Yang, E. David Crawford
      Abstract: Objective To determine whether an LHRH agonist, ATRIGEL® polymer‐delivered, subcutaneous, leuprolide acetate (ADSC‐LA) formulations suppressed testosterone to levels ≤20 ng/dL. Subjects/Patients and Methods Data from four open‐label, fixed‐dose studies were evaluated. Male patients aged 40‐86 years with advanced prostatic adenocarcinoma, whom had not undergone prior ADT, were treated with a depot formulation of ADSC‐LA: 7.5 mg [1 month (1M); N=120], 22.5 mg [3 months (3M); N=117], 30 mg [4 months (4M); N=90], or 45 mg [6 months (6M); N=111]. Serum testosterone was sampled at screening, baseline, 2, 4, 8 hours post‐dosing, days 1, 2, 3, 7, and every week until the next dose, at which time, the sampling schedule repeated until the end of study (24 weeks for 1M and 3M, 32 weeks for 4M, and 48 weeks for the 6M dose). The primary analyses were mean serum testosterone levels and proportion of patients who achieved serum testosterone levels ≤20 ng/dL. Results Mean serum testosterone levels at the end of study were consistently ≤20 ng/dL in each study (6.1±0.4, 10.1±0.7, 12.4±0.8, 12.6±2.1 for the 1M, 3M, 4M, and 6M doses, respectively). A high proportion of patients (94%, 90%, 92%, 96% for 1M, 3M, 4M, and 6M doses, respectively) achieved testosterone levels ≤20 ng/dL within 6 weeks, and 90‐97% of patients in all studies maintained testosterone ≤20 ng/dL from weeks 6‐24. Conclusions Recent studies have demonstrated improved outcomes in prostate cancer patients who consistently attained a more rigorous level of testosterone suppression (≤20 ng/dL) with androgen deprivation therapy (ADT) than the historical standard (≤50 ng/dL). All doses of ADSC‐LA rapidly achieved and maintained mean serum testosterone to the more rigorous target level of T ≤20 ng/dL. These data suggest that ADSC‐LA delivers equivalent testosterone suppression as achieved by surgical castration. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-17T21:50:34.285074-05:
      DOI: 10.1111/bju.13482
  • Posterior muscolofascial reconstruction after radical prostatectomy: an
           updated systematic review and a meta‐analysis
    • Authors: A. A. C. Grasso; F. A. Mistretta, M. Sandri, G. Cozzi, E. De Lorenzis, M. Rosso, G. Albo, F. Palmisano, A. Mottrie, A. Haese, M. Graefen, R. Coelho, V. R. Patel, B. Rocco
      Abstract: Objectives To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP). An updated systematic review of the literature. Material and Methods A systematic review of the literature was performed in June 2015, following the PRISMA statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the Title and Abstract fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta‐analysis of the risk ratios estimated using data from the selected studies was performed. Results Twenty‐one studies were identified in the literature search, including three randomized controlled trials. The overall analysis of comparative studies showed that PR improves the early continence recovery at 3‐7, 30 and 90 days after catheter removal, while continence rate at 6 months is statistically but not clinically affected. Statistically significant lower anastomotic leakage rates were described after PR. No significant differences were found in terms of positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. Conclusions The analysis confirms the benefits at 30 days post catheter removal already discussed in the review published in 2012 but also shows a significant advantage in terms of urinary continence recovery in the first 3 months. A multicenter prospective randomized controlled trial is currently conducted in several institutions all over the world to better assess the effectiveness of the PR in facilitating an earlier recovery of postoperative urinary continence. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-14T09:46:44.909135-05:
      DOI: 10.1111/bju.13480
  • Validation of the novel ISUP‐2014 5‐tier Gleason grade
           grouping: Biochemical recurrence rates of 3+5 disease may be overestimated
    • Authors: Roderick CN den Bergh; Theo H der Kwast, Jeroen Jong, Homayoun Zargar, Andrew J Ryan, Anthony J Costello, Declan G Murphy, Henk G der Poel
      Abstract: In 2014 the International Society of Urological Pathology (ISUP) supported to change the ISUP‐2005 modified Gleason scoring system, as previously proposed by Pierorazio et al.[1,2] Besides decisions on terminology and scoring of specific morphological patterns, a renumbering of the existing scores was suggested.[3] In clinical practice this comprises a transformation from a 6‐10 risk spectrum including 9 different Gleason scores (3+3=6, 3+4=7, 4+3=7, 3+5=8 4+4=8, 5+3=8, 4+5=9, 5+4=9, and 5+5=10) to a 1‐5 score with 5 grade groups (1: ≤3+3, 2: 3+4, 3: 4+3, 4: Gleason scores 8, and 5: Gleason score 9‐10). This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-12T09:27:05.035582-05:
      DOI: 10.1111/bju.13478
  • Assessment of energy density usage during 180W lithium triborate laser
           photo‐selective vaporization of the prostate for benign prostatic
           hyperplasia. Is there an optimal amount of kilo‐Joules per gram of
    • Abstract: Objectives The ideal amount of energy delivery during photo‐selective vaporization of the prostate (PVP) for optimal treatment of benign prostate hyperplasia (BPH) has not been established. The aim of this study is to assess the effect of energy density (kJ/cc) applied on adenoma during treatment on functional outcomes, PSA reduction and complications. Subjects/patients and methods After exclusions, a total of 440 patients that underwent Greenlight laser XPS 180W LBO PVP for the treatment of BPH were retrospectively reviewed. Data was collected from seven different international centers (Canada, the United States, the United Kingdom and France). Patients were stratified into four energy density groups (kJ/cc) according to intraoperative energy delivered and prostate volume as determined by pre‐operative trans‐rectal ultrasound (TRUS): group 1: 50%) at 6,12 and 24 months suggesting increased vaporization of adenoma tissue. However this did not translate into differences in functional outcomes at two years of follow‐up. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-11T07:26:36.838622-05:
      DOI: 10.1111/bju.13479
  • Risk of prostate cancer specific death in men with baseline metabolic
           aberrations treated with androgen deprivation therapy for biochemical
    • Authors: Sarah M. Rudman; Kathryn P. Gray, Julie L. Batista, Michael J. Pitt, Edward L. Giovannucci, Peter G. Harper, Massimo Loda, Lorelei A. Mucci, Christopher J. Sweeney
      Abstract: Objectives To investigate the association of host metabolic factors and the metabolic syndrome on prostate cancer specific death (PCSD) and overall survival (OS) in patients treated with androgen deprivation therapy (ADT) for biochemically recurrent disease. Patients and Methods The analysis included 273 prostate cancer patients treated with ADT for rising PSA after surgery or radiotherapy. Patients were assessed for the presence of diabetes, hypertension, dyslipidaemia, and obesity prior to the commencement of ADT and using ATPIII criteria for the presence of the composite diagnosis of metabolic syndrome (MS). Competing risks regression model assessed associations of time to PCSD with the metabolic conditions, while multivariable Cox regression model assessed associations of OS with MS and metabolic conditions. Results During a median follow‐up of 11.6 years, 157 (58%) patients died, of which 58 (21%) died of prostate cancer. At the start of ADT the median age was 74 (range=46, 92) years, the median PSA was 3.0 ng/mL. MS were observed in 31% patients; hypertension (68%) and dyslipidaemia (47%) were the most common metabolic conditions. No association of PCSD and MS status was observed. Patients with hypertension tended to have a higher cumulative incidence of PCSD compared to those without hypertension (sub‐distribution hazards ratio HR=1.59 (95%CI 0.89, 2.84; p‐value=0·11) though not statistically significant. Patients with MS had an increased risk of death from all causes (HR=1.56, 95%CI: 1.07, 2.29; p=0.02) when compared with patients without MS; as did patients with hypertension (HR=1·72, 95% CI: 1·18‐2·49; p=0·004). Conclusions No association of prostate cancer specific death and metabolic syndrome was observed in this cohort of men receiving ADT for biochemically recurrent prostate cancer. Patients with MS were associated with an increased risk of death from all causes and a similar effect was also observed for prostate cancer patients with hypertension alone. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-08T02:07:10.938437-05:
      DOI: 10.1111/bju.13428
  • Risk factors and timing of venous thromboembolism after radical cystectomy
           in routine clinical practice: a population‐based study
    • Authors: R. Christopher Doiron; Christopher M. Booth, Xuejiao Wei, D. Robert Siemens
      Abstract: Objective To describe the risk factors and timing of perioperative venous thromboembolism (VTE) and its association with survival for patients undergoing radical cystectomy (RC) in routine clinical practice. Patients and Methods The population‐based Ontario Cancer Registry was linked to electronic records of treatment to identify all patients who underwent RC between 1994 and 2008; VTE events were identified from hospital diagnostic codes. Multivariate logistic regression analysis was used to determine the factors associated with perioperative VTE. A Cox proportional hazards regression model explored the associations between VTE and survival. Results Of the 3 879 patients included in the study, 3.6% (141 patients) were diagnosed with VTE at ≤1 month of their surgical admission date. This increased to 4.7% (181) at ≤2 months and 5.4% (211) at ≤3 months. In all, 55% of VTE events presented after hospital discharge. In multivariate analysis, factors associated with VTE included higher surgeon volume (P = 0.004) and increased length of hospital stay (LOS; P < 0.001). Lymph node yield and adjuvant chemotherapy were not associated with VTE. VTE was associated with an inferior cancer‐specific survival [hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.13–1.62] and overall survival (HR 1.27, 95% CI 1.08–1.49). Conclusions Over half of VTE events in RC patients occur after hospital discharge, with a substantial incidence up to 3 months after surgery. Limited actionable risk factors for VTE were identified other than LOS. In this population‐based cohort, VTE was associated with inferior long‐term survival.
      PubDate: 2016-03-07T15:45:51.359963-05:
      DOI: 10.1111/bju.13443
  • Increasing age is not associated with toxicity leading to discontinuation
           of treatment in urothelial non muscle invasive bladder cancer patients
           randomized to receive 3 years of maintenance bacillus
           Calmette‐Guérin: Results from EORTC GU Group study 30911
    • Authors: Jorg R. Oddens; Richard J. Sylvester, Maurizio A. Brausi, Wim J. Kirkels, Cees de Beek, George Andel, Theo M. de Reijke, Stephen Prescott, J. Alfred Witjes, Willem Oosterlinck
      Abstract: Objectives To determine the relationship of age to side effects leading to discontinuation of treatment in stage Ta‐T1 NMIBC patients treated with maintenance bacillus‐Calmette‐Guérin (BCG). Patients and Methods We evaluated toxicity for 487 eligible intermediate or high risk Ta‐T1 (without CIS) non‐muscle‐invasive bladder cancer (NMIBC) patients randomized to receive 3 years of maintenance BCG (247 BCG alone and 240 BCG+INH) in EORTC trial 30911. The percent of patients who stopped for toxicity and the number of treatment cycles that they received were compared in 4 age groups, < 60, 61 ‐ 70, 71 – 75 and > 75 years of age, using the Mantel‐Haenszel chi square test for trend. Results The percent of patients stopping BCG for toxicity was 17.9% in patients < 60, 21.9% in patients 61 – 70, 22.9% in patients 71 – 75, and 16.4% in patients > 75 years of age (p = 0.90). For both systemic and local side effects, there was likewise no significant difference. Conclusions In intermediate and high risk Ta T1 urothelial bladder cancer patients treated with BCG, no differences in toxicity as a reason for stopping treatment were observed based on age. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-06T06:48:35.963327-05:
      DOI: 10.1111/bju.13474
  • The association of eNOS G894T gene polymorphisms with responsiveness to
           α1‐blocker in men with BPH/LUTS
    • Abstract: Objective Nitric oxide (NO) has recently gained increasing recognition as an important neurotransmitter of functions in the lower urinary tract. This prospective study firstly investigated the association of eNOS G894T gene polymorphism with the responsiveness to α1‐blocker in men with benign prostatic hyperplasia related lower urinary tract symptoms (BPH/LUTS). Materials and Methods 136 patients with BPH/LUTS were recruited from urology outpatient clinics in a university hospital. Oral therapy with doxazosin‐ GITS 4 mg once‐daily was given for 12 weeks. The drug efficacy was assessed by the changes from baseline in the total International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax) and post‐void residual urine volume (PVR) at 12 weeks of treatment. The responders to doxazosin GITS were defined as those who had a total IPSS decrease of more than 4 points from baseline. The eNOS G894T polymorphisms were determined using the polymerase chain reaction‐restriction fragment length polymorphism (PCR‐RFLP) method Results Patients had statistically significant improvements in total IPSS, QoL and Qmax (P
      PubDate: 2016-03-04T03:46:44.757585-05:
      DOI: 10.1111/bju.13468
  • The Final Robotic Frontier: Evolution and Current State of the
           Robotic‐Assisted Radical Cystectomy
    • Authors: Tony Tran; Nicholas Raison, Norbert Doeuk, Prokar Dasgupta
      Abstract: Radical cystectomy with pelvic lymphadenectomy and urinary diversion has long been the standard of care for the treatment of non‐metastatic muscle‐invasive urothelial carcinoma of the bladder. Historically the procedure was performed through an open technique. With the potential benefits of decreased blood loss, quicker return of bowel function, and shorter postoperative convalescence minimally invasive techniques began to be described in the 1990s. Menon et al performed the first robotic‐assisted radical cystectomy in 2003 and the first centres soon adopted the procedure (1). Yet surprisingly, unlike other robotic‐assisted procedures, the technique has not enjoyed a similarly meteoric rise. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-04T03:45:48.551536-05:
      DOI: 10.1111/bju.13471
  • Role of Survivin expression in predicting biochemical recurrence after
           radical prostatectomy: a multi‐institutional study
    • Abstract: Objective To assess the association of Survivin expression with clinicopathological features and biochemical recurrence (BCR) after radical prostatectomy (RP) in a large multi‐institutional cohort. Methods Survivin expression was evaluated by immunohistochemistry on a tissue microarray of RP cores from 3117 patients. Survivin expression was considered altered when at least 10% of the tumor cells stained positive. Association of altered Survivin expression with BCR was evaluated using Cox proportional hazards regression models. Results Survivin expression was altered in 1330 (42.6%) patients. Altered expression was associated with higher Gleason score on RP (p=0.001), extracapsular extension (p=0.019), seminal vesicle invasion (p
      PubDate: 2016-03-04T03:44:45.592206-05:
      DOI: 10.1111/bju.13472
  • Combination of PI‐RADS score and PSA density predicts biopsy outcome
           in biopsy naïve patients
    • Authors: Satoshi Washino; Tomohisa Okochi, Kimitoshi Saito, Tsuzumi Konishi, Masaru Hirai, Yutaka Kobayashi, Tomoaki Miyagawa
      Abstract: Objective To assess the value of the Prostate Imaging Reporting and Data System (PI‐RADS) scoring system, for prostate multi‐parametric magnetic resonance imaging (mpMRI) to detect prostate cancer, and classical parameters, such as prostate specific antigen (PSA), prostate volume and PSA density, for predicting biopsy outcome in biopsy naïve patients who have suspected prostate cancer (PCa). Patients and methods Patients who underwent mpMRI at our hospital, and who had their first prostate biopsy between July 2010 and April 2014, were analysed retrospectively. The prostate biopsies were performed transperineally under transrectal ultrasound guidance. Fourteen cores were biopsied as a systemic biopsy in all patients. Two cognitive fusion‐targeted biopsy cores were added for each lesion in patients who had suspicious or equivocal lesions on mpMRI. The PI‐RADS scoring system ver. 2.0 (PI‐RADS v2) was used to describe the MRI findings. Univariate and multivariate analyses were performed to determine significant predictors of PCa and clinically significant PCa. Results In total, 288 patients were analysed. Median patient age, PSA, prostate volume and PSA density were 69, 7.5 ng/mL, 28.7 cm3 and 0.26 ng/mL/cm3, respectively. The biopsy results were benign, clinically insignificant and clinically significant PCa in 129 (45%), 18 (6%) and 141 (49%) patients, respectively. The multivariate analysis revealed that PI‐RADS v2 score and PSA density were independent predictors for PCa and clinically significant PCa. When PI‐RADS v2 score and PSA density were combined, PI‐RADS v2 score > 4 and PSA density > 0.15, or PI‐RADS v2 score 3 and PSA density > 0.30, was associated with the highest clinically significant PCa detection rates (76–97%) on the first biopsy. Of the patients in this group with negative biopsy results, 22% were subsequently diagnosed as PCa. In contrast, PI‐RADS v2 score < 3 and PSA density < 0.15 yielded no clinically significant PCa and no additional detection of PCa on further biopsies. Conclusions A combination of PI‐RADS v2 score and PSA density can help in the decision‐making process before prostate biopsy and the follow‐up strategy in biopsy naïve patients. Patients with PI‐RADS v2 score < 3 and PSA density < 0.15 may avoid unnecessary biopsies. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-02T21:56:51.4284-05:00
      DOI: 10.1111/bju.13465
  • Impact of tumor size on prognosis of upper urinary tract urothelial
           carcinoma after radical nephroureterectomy: a multi‐institutional
           analysis of 795 cases
    • Authors: Shibing Yan; Liangren Liu, Qiang Wei, Hong Liao, Turun Song, Junhao Lei, Lu Yang, Zhengyong Yuan, Yonghao Jiang, Guangqing Fu, Yunxiang Li, Dehong Cao
      Abstract: Objective To evaluate the prognostic impact of tumor size on survival outcomes in upper urinary tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU). Patients and Methods Data on 795 patients treated with RNU for UTUC from 7 centers were retrospectively analyzed with focus on tumor size. Clinicopathological features and relevent prognostic factors were compared between patients with tumor size ≤3.0cm and >3.0cm. The primary end points were cancer specific survival (CSS), disease recurrence‐free survival (DFS), and overall survival (OS). Results At a median follow‐up of 32 months, 313 (39.4%) patients died of UTUC, 321 (40.4%) developed cancer relapse, and 359 (45.1%) died of all causes. Tumor size >3.0cm was associated with unfavorablly clinicopathlogical features. On Kaplan–Meier analysis, tumor size was significantly correlated with worse CSS, DFS and OS(all p
      PubDate: 2016-03-02T21:41:20.566587-05:
      DOI: 10.1111/bju.13463
  • The safety of robot‐assisted cystectomy in patients with previous
           history of pelvic irradiation
    • Authors: Bashir Al Hussein Al Awamlh; Daniel P. Nguyen, Brandon Otto, Padraic O'Malley, Farehin Khan, Savanah Brooks, Douglas S. Scherr
      Abstract: Objective To determine the safety of robot‐assisted cystectomy in patients with an irradiated pelvis, by comparing perioperative complication outcomes after robot‐assisted cystectomy in patients with and without a history of pelvic irradiation. Patients and Methods A total of 252 consecutive patients underwent robot‐assisted cystectomy at a tertiary referral center from 2002 and 2013. Of all patients, 46 (18%) had a history of pelvic irradiation. ● Complications occurring within 30 days and 90 days of surgery were graded using the modified Clavien classification system and additionally categorized by organ system. ● Baseline variables and outcomes of irradiated and non‐irradiated patients were compared using descriptive statistics. Multivariable logistic regression models were generated to test the effect of previous pelvic irradiation on complications. Results The indications for robot‐assisted cystectomy in patents with a history of pelvic irradiation were: bladder cancer (n=30, 65%), prostate cancer (n=2, 4%), fistulas (n=5, 11%) and intractable symptoms from radiation cystitis (n=9, 20%). ● A total of 25 (54%) irradiated and 112 (54%) non‐irradiated patients had complications within 90 days (p>0.9), of which 11 (24%) and 43 (21%) had major complications (p=0.7). ● One (2%) patient with and two (1%) patients without a history of irradiation died from surgical complications (p=0.5). ● Infectious, bleeding and gastrointestinal complications were the most common events in both groups. ● In multivariable analyses, a history of pelvic irradiation was not associated with higher risk of complications. Conclusion Robot‐assisted cystectomy performed by an experienced surgeon is a reasonable option in selected patients with a history of pelvic irradiation, as complication rates do not significantly differ compared to non‐irradiated patients. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-02T21:41:08.622367-05:
      DOI: 10.1111/bju.13464
  • Complications and quality of life in elderly patients with high
           comorbidities who underwent cutaneous ureterostomy with single stoma or
           ileal conduit after radical cystectomy
    • Authors: Nicola Longo; Ciro Imbimbo, Ferdinando Fusco, Vincenzo Ficarra, Francesco Mangiapia, Giuseppe Di Lorenzo, Massimiliano Creta, Vittorio Imperatore, Vincenzo Mirone
      Abstract: Objectives To compare perioperative outcomes and quality of life (QoL) in a series of elderly patients with high co‐morbidity status who underwent single stoma cutaneous ureterostomy (CU) or ileal conduit (IC) after radical cystectomy (RC). Subjects and methods Clinical records of patients older than 75 years with an American Society of Anesthesiologists (ASA) score > 2 who underwent RC at a single institution between March 2009 and March 2014 were retrospectively analyzed. After RC, all patients included in the study received an IC urinary diversion or a CU with single stoma urinary diversion. Preoperative clinical characteristics as well as intra and post‐operative outcomes were evaluated and compared in the two groups. Moreover, the Bladder Cancer Index (BCI) was used to assess QoL. Results A total of 70 patients were included into the final comparative analyses. Of them, 35 underwent IC diversion and 35 CU with single stoma diversion. The two groups were comparable for age, gender, ASA score, type of indication and pathological features. Operative times (p
      PubDate: 2016-03-02T21:36:50.748375-05:
      DOI: 10.1111/bju.13462
  • Direct comparison of multiparametric MRI and final histopathology in
           patients with proven prostate cancer in MRI/Ultrasound‐fusion biopsy
    • Authors: Angelika Borkowetz; Ivan Platzek, Marieta Toma, Theresa Renner, Roman Herout, Martin Baunacke, Michael Laniado, Gustavo Baretton, Michael Froehner, Stefan Zastrow, Manfred Wirth
      Abstract: Objectives To compare multiparametric magnetic resonance imaging of the prostate (mpMRI) and histological findings of targeted MRI/ultrasound‐fusion biopsy (fusPBx) and systematic biopsy (sysPBx) to final histology of prostatectomy specimen (PrS). Patients and methods 105 patients with histopathologically proven prostate cancer (PCa) by combination of fusPbx and sysPBx and undergoing radical prostatectomy were investigated. All patients had been examined by mpMRI, applying the European Society of Urogenital Radiology criteria. Histological findings of PrS were compared to those of the biopsy. Whole mount PrS and MR‐images were compared directly by a uro‐pathologist and a uro‐radiologist in step‐section analysis. Results 105 patients with histopathologically proven PCa by combination of fusPBx and sysPBx (combPBx) were investigated. The detection rate of PCa was 90% (94/105) in fusPBx alone and 68% (72/105) in sysPBx alone (p=0.001). CombPBx detected 23 (22%) Gleason Score (GS) 6, 69 (66%) GS 7 and 13 (12%) GS ≥8 tumours. FusPBx alone detected 25 (26%) GS 6, 57 (61%) GS 7 and 12 (13%) GS ≥8 tumours. SysPBx alone detected 17 (24%) GS 6, 49 (68%) GS 7 and 6 (8%) GS ≥8 tumours. FusPBx alone would have missed 11 tumours (4% (4/105) (GS) 6; 6% (6/105) GS 7; 1% (1/105) GS ≥8), sysPBx alone would have missed 33 tumours (10% (10/105) GS 6; 20% (21/105) GS 7; 2% (2/105) GS ≥8). Concordance on GS between biopsy and PrS was 63% (n=65), 54% (n=56) and 75% (n=78) in fusPBx, in sysPBx and in the combination of both biopsy modalities (combPBx), respectively. Upgrading on GS between biopsy and PrS occurred in 33% (n=34), 44% (n=46) and 18% (n=19) in fusPBx, sysPBx and combPBx, respectively. Gamma correlation for detection of any cancer was 0.76 for combPBx, 0.68 for fusPBx alone and 0.23 for sysPBx alone. 84% (n=88) of index tumours could be identified by mpMRI; 86% (n=91) of index lesions in the mpMRI could be proven in PrS. Conclusions FusPBx of tumour suspicious lesions in mpMRI was associated with a higher detection rate of more aggressive PCa and a better tumour prediction in final histopathology than sysPBx alone. But combPBx has been shown the best concordance for the prediction of GS. Furthermore, the additional findings of sysPBx reflect the multifocality of PCa. Hence, the combination of both biopsy modalities would still present the best approach for the prediction of the final tumour grading in PCa. This article is protected by copyright. All rights reserved.
      PubDate: 2016-03-02T21:32:02.918525-05:
      DOI: 10.1111/bju.13461
  • The ERSPC Risk Calculators Significantly Outperform The PCPT 2.0 In The
           Prediction Of Prostate Cancer; A Multi‐Institutional Study
    • Authors: Robert W. Foley; Robert M. Maweni, Laura Gorman, Keefe Murphy, Dara J. Lundon, Garrett Durkan, Richard Power, Frank O'Brien, Kieran J. O'Malley, David J. Galvin, T. Brendan Murphy, R. William Watson
      Abstract: Introduction To analyse the performance of the Prostate Cancer Prevention Trial Risk Calculator (PCPT‐RC) and two iterations of the European Randomised Study of Screening for Prostate Cancer Risk Calculator (ERSPC‐RC), one of which incorporates prostate volume and another which incorporates prostate volume and the Prostate Health Index (ERSPC‐PHI) in a referral population. Methods The risk of prostate cancer (PCa) and significant PCa (Gleason ≥7) in 2,001 patients from 6 tertiary referral centres was calculated according to the PCPT‐RC and ERSPC‐RC formulae. The calculators’ predictions were analysed using the area under the receiver operating characteristics curve (AUC), calibration plots, Hosmer‐Lemeshow test for goodness of fit and decision curve analysis. In a subset of 222 patients for whom the Prostate Health Index (PHI) score was available, each patient's risk was calculated as per the ERSPC‐RC and ERSPC‐PHI risk calculator. Results The ERSPC‐RC outperformed the PCPT‐RC in the prediction of PCa, with an AUC of 0.71 compared to 0.64 and also outperformed the PCPT‐RC in the prediction of significant PCa (p
      PubDate: 2016-02-29T22:56:38.094549-05:
      DOI: 10.1111/bju.13437
  • Prostate specific antigen patterns in US and European populations:
           comparison of six diverse cohorts
    • Abstract: Objective To determine whether there are differences in prostate specific antigen (PSA) at diagnosis or changes in PSA between US and European populations of men with and without prostate cancer. Subjects and methods Repeated measures of PSA from six clinically and geographically diverse patient cohorts: two cohorts of men with PSA‐detected prostate cancer, two cohorts with clinically‐detected prostate cancer and two cohorts of men without prostate cancer. Using multilevel models, average PSA at diagnosis and PSA change over time were compared between populations. Results Annual percentage PSA change of 4‐5% was similar between men without cancer and men with PSA‐detected cancer. PSA at diagnosis was 1.7ng/ml lower in a US cohort of PSA‐detected men (95% CI 1.3‐2.0ng/ml), compared to a PSA‐detected UK cohort, but there was no evidence for a different rate of PSA change between these populations. Conclusion PSA changes over time are similar in UK and US men diagnosed through PSA testing and even in men without prostate cancer. Further development of PSA models to monitor men on active surveillance should be undertaken in order to take advantage of these similarities. We found no evidence that guidelines for using PSA to monitor men cannot be passed between US and European studies. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-29T06:56:27.377917-05:
      DOI: 10.1111/bju.13422
  • Predictive Value of Negative 3T Multiparametric Prostate MRI on 12 Core
           Biopsy Results
    • Authors: James S. Wysock; Neil Mendhiratta, Fabio Zattoni, Xiaosong Meng, Marc Bjurlin, William C. Huang, Herbert Lepor, Andrew B. Rosenkrantz, Samir S. Taneja
      Abstract: Objectives To evaluate the cancer detection rates (CDR) for men undergoing 12 core systematic prostate biopsy with negative prebiopsy mpMRI (NegMR). Materials & Methods Clinical data from consecutive men undergoing prostate biopsy with prebiopsy 3T mpMRI from December 2011 to August 2014 were reviewed from an IRB approved prospective database. Prebiopsy mpMRI was read by a single radiologist and men with NegMR prior to biopsy were identified for this analysis. Clinical features, CDR, and NPV rates were summarized. Results Seventy five men underwent SPB with a NegMRI during the study period. For the entire cohort, men with no prior biopsy, men with prior negative biopsy, and men enrolled in active surveillance protocols, overall CDR was 18.7%, 13.8%, 8.0% and 38.1%, respectively, and detection of Gleason sum ≥ 7 (GS≥7) cancer was 1.3%, 0%, 4.0% and 0%, respectively. The NPV for all cancers was 81.3%, 86.2%, 92.0%, and 61.9%, and for GS≥7 cancer was 98.7%, 100%, 96.0% and 100%, respectively. Conclusions Negative prebiopsy mpMRI confers an overall NPV of 82% on 12 core biopsy for all cancer and 98% for GS≥7. Based upon biopsy indication, these findings assist in prebiopsy risk stratification for detection of high risk disease and may provide guidance in the decision to pursue biopsy. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-25T23:07:28.572673-05:
      DOI: 10.1111/bju.13427
  • Abnormal Akt signaling in bladder epithelial cell explants from IC/BPS
           patients can be induced by antiproliferative factor treatment of normal
           bladder cells
    • Abstract: Objectives Explanted bladder epithelial cells from IC/BPS patients produce a frizzled 8‐related glycopeptide antiproliferative factor (APF) that inhibits normal bladder epithelial cell proliferation and expression of several proteins known to be regulated by Akt signaling. • Our primary objective was to determine whether Akt signaling and secretion of specific downstream effector proteins are abnormal in specific cell fractions of IC/BPS bladder epithelial cells. • A related secondary objective was to determine whether treatment of normal bladder epithelial cells with active synthetic asialo‐antiproliferative factor (as‐APF) induces similar changes in Akt signaling and specific downstream effector proteins/mRNAs. Patients and Methods • Cell proteins were extracted into four subcellular fractions from primary bladder epithelial explants of six patients who fulfilled modified NIDDK criteria for IC/BPS and six age‐ and gender‐ matched controls. • Total and/or phosphorylated cellular Akt, GSK3β, and β‐catenin; total cellular JunB; and secreted MMP2 and HB‐EGF levels were determined by Western blot. • MMP2, JunB, p53, UPK3, and β‐actin mRNAs were quantified by qRT‐PCR. • Akt activity was determined by nonradioactive assay. Results • IC/BPS cells had decreased Akt activity, along with decreased Akt ser473‐ and GSK3β ser9‐phosphorylation and increased β‐catenin ser33,37/thr41‐phosphorylation in specific fractions as compared to matched control cells. • IC/BPS explants also had evidence for additional downstream abnormalities as compared to control cells, including decreased nuclear JunB; decreased secreted MMP2 and HB‐EGF; plus decreased MMP2, JunB, and UPK3 mRNAs but increased p53 mRNA relative to β‐actin. • Each of these IC/BPS cell abnormalities was also induced in normal cells by as‐APF. Conclusion • These findings indicate that IC/BPS cells have abnormal Akt activity with downstream protein expression abnormalities including decreased MMP2 and HB‐EGF secretion. • They also support the hypothesis that APF plays a role in the pathogenesis of IC/BPS via its effects on cell Akt signaling and HB‐EGF production. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-25T06:58:23.017877-05:
      DOI: 10.1111/bju.13457
  • The Accuracy of Prostate Biopsies for Predicting Gleason Score in Radical
           Prostatectomy Specimens. Nationwide trends 2000‐2012
    • Abstract: Objectives To investigate how well the Gleason score in diagnostic needle biopsies predicted the Gleason score in a subsequent radical prostatectomy (RP) specimen before and after the 2005 International Society of Urological Pathology (ISUP) revision of Gleason grading, and if the recently proposed ISUP grades 1‐5 (corresponding to Gleason score 6, 3+4, 4+3, 8, and 9‐10) better predict the RP grade. Patients and Methods All prostate cancers diagnosed in Sweden are reported to the National Prostate Cancer Register (NPCR). We analysed Gleason score and ISUP grades from the diagnostic biopsies and RP specimens from 15,598 men in the NPCR who were diagnosed between 2000 and 2012 with clinical stage T1‐2 M0/X prostate cancer on needle biopsy at age ≤ 70 years, had serum PSA of
      PubDate: 2016-02-25T06:58:05.674273-05:
      DOI: 10.1111/bju.13458
  • Factors predicting progression to castrate‐resistant prostate cancer
           in patients with advanced prostate cancer receiving long‐term
           androgen deprivation therapy
    • Abstract: Objectives To assess time to progression to castrate‐resistant prostate cancer (CRPC) and factors influencing longer‐term outcomes in patients receiving ADT in an extension to the Triptocare study (NCT01020448). This is pertinent as the Triptocare study did not show that urinary PCA3 score was a reliable marker of cancer stage in advanced prostate cancer and was not useful for assessing response 6 months after initiation of androgen deprivation therapy (ADT) with triptorelin 22.5 mg. Patients and methods An international, multicentre, non‐interventional, observational, longitudinal, prospective study involving patients from the Triptocare study. CRPC status of patients was collected for up to 3 years from ADT initiation. Patient treatment and assessments were at the investigator's discretion. Co‐primary endpoints were rate of CRPC 3 years after initiating ADT and median time to CRPC. An exploratory endpoint was association of Triptocare baseline variables (including TMPRSS2‐ERG score and PCA3 score) and PCA‐3 score at Triptocare last value available with CRPC onset. Results Of the 325 patients in the Triptocare study safety population, 180 patients were enrolled in the Triptocare LT study (102 received continuous and 78 received intermittent ADT). CRPC rates at 3 years were 24/102 (23.5%) and 6/78 (7.7%) patients in the continuous and intermittent ADT groups, respectively. Median time to CRPC was not reached for either group. PCA3 score status at baseline was the only variable associated with a higher risk of progression to CRPC in both the intermittent and continuous ADT groups; compared with a baseline PCA3 score ≥35, PCA3 score below the level of quantification (BLQ) had a hazard ratio (HR) of 20.04 (95% CI: 2.71–148.34) and a HR=9.44 (95% CI: 2.39–37.27), respectively. Baseline metastatic disease and testosterone were additionally associated with progression to CRPC in the continuous ADT population: HR=5.20 (95%CI: 1.68–16.06) and HR=0.995 (95%CI: 0.991–0.999), respectively. Conclusion In men with locally‐advanced or metastatic prostate cancer, a PCA3 score ≥35 at time of initiating ADT may predict a lower risk of developing CRPC in the following 3 years. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-25T06:54:42.391918-05:
      DOI: 10.1111/bju.13455
  • No evidence (yet) to support the statement “LUTS – an
           independent risk factor for cardiovascular disease”
    • Abstract: In a recent volume of this journal, the possible association between LUTS and cardiovascular disease (CVD) was highlighted [1, 2]. This topic is of interest with an ageing population. Particularly in urology, the consultation rates for male LUTS highly depend on patient age. Fortunately, nowadays specialists see their patients in a broader perspective, than their single condition, taking comorbidities into consideration as well. The growing attention for CVD risk in men with LUTS illustrates this. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-25T06:53:48.184319-05:
      DOI: 10.1111/bju.13456
  • Mid‐term outcome after AdVanceXP male sling implantation
    • Authors: Alexander Kretschmer; Markus Grabbert, Anne Sommer, Christian G. Stief, Ricarda M. Bauer
      Abstract: Objective To describe efficacy and safety of the AdVanceXP retrourethral transobturator male sling after a mean follow‐up of almost 3 years. Patients and methods 41 patients received AdVanceXP implantation between July 2010 and March 2012 by a single surgeon. Patients were prospectively evaluated at baseline, after a mean follow‐up of 12 months and after an individual maximum follow‐up. Efficacy was evaluated by daily pad usage, 24hrs pad testing, and validated questionnaires (ICIQ‐SF). Patient satisfaction was determined using the PGI score; quality of live was evaluated using the IQOL score. Patients needing no pad or one safety pad with a daily urine loss
      PubDate: 2016-02-25T06:53:16.371459-05:
      DOI: 10.1111/bju.13459
  • Impact of the lack of community urinary catheter care services on the
           Emergency Department
    • Authors: Li June Tay; Hannah Lyons, Irene Karrouze, Claire Taylor, Azhar A. Khan, Peter M. Thompson
      Abstract: Objectives To conduct an audit of patients presenting with long‐term urinary catheter (LTC)‐associated problems to our Emergency Department (ED) and to assess the availability of community nursing support for their LTC. We also estimated the cost implication to the health service and the potential solutions to this issue, as although catheter care is provided by community nurses, LTC problems are common presentations to the ED and are often significant burdens to the services. Patients and Methods A study was carried out of all patients presenting to the ED with a urinary catheter problem, specifically studying LTCs and the reason for presentation, district nurses' involvement, and the intervention received. Results In all, 78 patients with a urinary catheter problem presented to the ED over a 69‐day period, of whom 59 (68%) had a LTC. In all, 33 patients (42%) attended during normal working hours between 0900 and 1700 h. The mean (range) age was 74 (42–93) years and the duration the LTC had been in situ was 11 (1–120) months. The most common reasons for attendance were blocked catheter (37 patients, 47%) and catheter‐bypass (18, 23%). Only 28 patients (36%) were known to district nursing services, and 14% were referred by a district nurse. Most of the remaining patients self‐referred to the ED. No patient had any documented contact with their general practitioner. In addition, 64 patients (82%) had their catheter issues addressed adequately by ED nurses or doctors, without any urology involvement. Conclusions The high morbidity of LTCs causes a considerable demand on ED services, and has heavy cost implications to the health system. Most patients had minimal community nurse support, and their catheter problems were easily dealt with by ED nurses and doctors.
      PubDate: 2016-02-25T04:03:05.05046-05:0
      DOI: 10.1111/bju.13430
  • Diffusion‐weighted Imaging (DWI) Predicts Upgrading of Gleason Score
           in Biopsy‐proven Low‐grade Prostate Cancers
    • Authors: Sung Yoon Park; Young Taik Oh, Dae Chul Jung, Nam Hoon Cho, Young Deuk Choi, Koon Ho Rha, Sung Joon Hong
      Abstract: Objective To analyze whether diffusion‐weighted imaging (DWI) predicts Gleason score (GS) upgrading in biopsy‐proven low‐grade prostate cancers. Patients and Methods A total of 132 patients who have biopsy‐proven low‐grade (GS< 7) prostate cancers, 3T DWI, and surgical confirmation were retrospectively included. Clinical [prostate‐specific antigen, greatest percentage of biopsy core, and percentage of positive core number] and DWI parameters [minimum apparent diffusion coefficient (ADCmin) and mean ADC (ADCmean)] were evaluated. ADCmin was measured using a region‐of‐interest of 5‐10 mm2 at the area of lowest ADC value within a cancer, while ADCmean was measured using a region‐of‐interest covering more than half of a cancer by two independent, blinded readers, respectively. Logistic regression and receiver operating‐characteristic curve analyses were performed. Results The rate of GS upgrading was 46.1% (61/132). In both univariate and multivariate analyses, ADCmin and ADCmean were persistently significant for predicting GS upgrading (p< 0.05), whereas clinical parameters were not (p> 0.05). In both readers, the area of under curve (AUC) of ADCmin was significantly greater than that of ADCmean (AUCs of reader 1, 0.760 versus 0.711, p< 0.001; AUCs of reader 2, 0.752 versus 0.714, p= 0.003). Conclusion DWI may predict GS upgrading of biopsy‐proven low‐grade prostate cancers. The use of cancer ADCmin may allow better performance than ADCmean. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-24T23:17:58.236985-05:
      DOI: 10.1111/bju.13436
  • Endogenous and exogenous testosterone and the risk of prostate cancer and
           increased prostate specific antigen (PSA): a meta‐analysis
    • Authors: Peter Boyle; Alice Koechlin, Maria Bota, Alberto d'Onofrio, David G. Zaridze, Paul Perrin, John Fitzpatrick, Arthur L. Burnett, Mathieu Boniol
      Abstract: Objective To review and quantify the association between endogenous and exogenous testosterone and prostate specific antigen (PSA) and prostate cancer. Methods Literature searches were performed following the PRISMA guidelines. Prospective cohort studies that reported data on the associations between endogenous testosterone and prostate cancer, and placebo controlled randomised trials of testosterone replacement therapy (TRT) that reported data on PSA and/or prostate cancer cases were retained. Meta‐analyses were performed using random‐effects models with tests for publication bias and heterogeneity. Results Twenty estimates were included in a meta‐analysis which produced a summary relative risk of prostate cancer for an increase of 5 nmol/L of testosterone of 0.99 (95% CI (0.96, 1.02)) without heterogeneity (I² = 0%). Based on 26 trials, the overall difference in PSA levels following onset of use of TRT was 0.10 ng/mL (‐0.28, 0.48). Results were similar when conducting heterogeneity analyses by mode of administration, region, age at baseline, baseline testosterone, trial duration, type of patients and type of testosterone replacement therapy. The summary relative risk of prostate cancer as an adverse effect from 11 TRT trials was 0.87 (0.30; 2.50). Results were consistent across studies. Conclusions Prostate cancer appears to be unrelated to endogenous testosterone levels. Testosterone replacement therapy for symptomatic hypogonadism does not appear to increase PSA levels nor the risk of prostate cancer development. The current data are reassuring although some care is essential until multiple studies with longer follow‐up are available. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-24T09:06:47.754987-05:
      DOI: 10.1111/bju.13417
  • Significant reduction of positive surgical margin rate following
           Laparoscopic Radical Prostatectomy by application of the modified surgical
           margin recommendations according to the International Society of
           Urological Pathology (ISUP) consensus 2009
    • Abstract: Objectives To retrospectively verify the exact margin status and analyze the location and characteristics of positive surgical margins (PSM) in radical prostatectomy patients by a central pathology review based on the consensus conference 2009 updated margin criteria from the International Society of Urological Pathology (ISUP). Patients and Methods Detailed PSM characteristics of 441 patients who underwent laparoscopic radical prostatectomy (LRP) between 1999 and 2007 were centrally reviewed with regard to location, number, Gleason score at the PSM and tumor width. Predictors of PSM and the impact of several PSM‐characteristics on clinical outcome were examined. Patient characteristics were compared by using chi square test. Differences in recurrence‐free‐survival (RFS) were analyzed with the log‐rank test and displayed by Kaplan‐Meier survival curves. Uni‐ and multivariable cox regression analysis for the prediction of RFS was performed. Results Central pathology review including the updated PSM definition according to ISUP 2009 reclassified a substantial number of patients (n=113, 26.6%). with PSM as R0. Several PSM characteristics with a higher risk for BCR were identified: Pathological stage, Gleason score and the presence of multiple PSM (HR 1.78; 95% CI 1.08‐2.96; p=0.025) were the strongest independent predictors of RFS. Further analysis replacing the location of PSM by the width categories of PSM revealed that PSM >3mm were independent predictors of RFS (HR 1.72; 95% CI 1.08‐2.72; p=0.022). Conclusions The impact of PSM following LRP for prostate cancer remains unclear. PSM in our LRP cohort inherit different characteristics and risks for BCR. A better understanding of PSM characteristics and a careful standardized pathological evaluation is needed to adequately counsel patients with respect to prognosis and adjuvant therapy following LRP. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-24T06:45:05.414625-05:
      DOI: 10.1111/bju.13451
  • Outcomes of single versus double cuff artificial urinary sphincter
           insertion in low and high risk profile male patients with severe stress
           urinary incontinence
    • Abstract: Objectives To evaluate continence and complication rates of bulbar single and distal bulbar double cuff insertion according to low and high risk for unfavorable artificial urinary sphincter outcomes. Patients and Methods 180 patients who underwent artificial urinary sphincter implantation between 2009 and 2013 were followed according to institutional standards. Patients with previous pelvic radiation therapy, open bulbar urethral or incontinence surgery (“high risk”) underwent distal bulbar double cuff (n=123), all others (“low risk”) proximal bulbar single cuff (n=57) placement. Primary and secondary endpoints consisted of continence and complication rates. Kaplan‐Meier analysis determined explantation‐free survival, Cox regression models assessed risk factors for persistent incontinence and explantation. Results Median follow‐up was 24 months. Whereas no significant difference in pad usage/objective continence was observed after single vs. double cuff insertion, superior rates of subjective/social continence and less persistent incontinence were reported by double cuff patients (all p≤0.02). Overall, device explantation (erosion, infection or mechanical failure) occured in 12.8%. While early (0.05), double cuff patients had a 5.7‐fold higher risk of device explantation in the late follow‐up (p=0.02) and significantly shorter explantation‐free‐suvival (log‐rank: 0.003). Conclusions Distal bulbar double cuff insertion in patients with a “high risk” profile (previous pelvic radiation, urtehral surgery) leads to similar objective continence, but increased explantation rates when compared to “low risk” proximal bulbar single cuff. Randomized controlled trials comparing both devices will need to differ if higher explanations rates attribute to the double cuff device or risk factors. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-24T06:44:51.727293-05:
      DOI: 10.1111/bju.13449
  • Optimal Management of Non‐Muscle Invasive Micropapillary Variant
           Urothelial Carcinoma: Possibility For Missed Chance at Cure'
    • Authors: Stephen B. Williams; Ashish M. Kamat
      Abstract: Bladder cancer is a common disease in the US, affecting upwards of 74,000 patients yearly 1. Micropapillary bladder carcinoma (MPBC) is a sub type variant which was described in 1994 from our institution and which has gained in recognition since then. Due to small numbers of patients, most series other than those from major cancer centers have been in the single or low double digits. We have previously reported on the relative ‘resistance’ of this variant subtype to intravesical immunotherapy and advocated for early radical cystectomy to provide optimal cancer control for our patients. This is in contrast to the undisputed clinical benefit of Bacille Calmette and Guérin (BCG) immunotherapy for patients with conventional non‐muscle invasive bladder cancer (NMIBC) in reducing not only recurrence but also progression rates. However, since some have argued that intravesical immunotherapy is an appropriate mode of therapy even for MPBC, there is potential for missed chance of cure. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-24T06:44:39.02507-05:0
      DOI: 10.1111/bju.13450
  • Biochemical composition of urolithiasis from stone dust ‐ a matched
           pair analysis
    • Authors: Eleanor R Ray; Gill Rumsby, R D Smith
      Abstract: Objective To determine if the biochemical composition of a renal calculus can be measured from “dust” obtained during laser fragmentation. Patients and methods Pilot study set in a tertiary referral hospital between 2011‐2013. Stone dust was aspirated through the ureteroscope during lasering and a stone fragment also retrieved. Both samples were analysed by Fourier transform infrared spectroscopy. Pairs of stone (standard) and dust were compared. They were deemed to match if both were of the same pure biochemical composition or if the predominant constituent was the same in mixed compositions, as this would not alter subsequent management. Results Paired specimens were obtained from 97 ureteroscopies. The dust specimen was sufficient for analysis in 66/97(68%) cases. Of these, the composition matched that of the stone in 49/66(74%) cases. In 12/66(18%) the biochemistry differed only in the relative proportions of each constituent, whilst 5/66 (8%) showed a complete mismatch. The overall sensitivity was 51% and specificity 97%. A limitation of the study is the small number of some stone types analysed (< 5 each cystine, atazanavir, mixed uric acid/calcium oxalate). Conclusion We have demonstrated in this pilot study successful proof of principle. Further work is required initially to improve the number of sufficient dust specimens. This technique may offer an option when a stone cannot be retrieved ureteroscopically. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-24T06:43:26.830741-05:
      DOI: 10.1111/bju.13448
  • Radiographic Size of Retroperitoneal Lymph Nodes Predicts Pathologic Nodal
           Involvement for Patients with Renal Cell Carcinoma: Development of a Risk
           Prediction Model
    • Authors: Boris Gershman; Naoki Takahashi, Daniel M. Moreira, Robert H. Thompson, Stephen A. Boorjian, Christine M. Lohse, Brian A. Costello, John C. Cheville, Bradley C. Leibovich
      Abstract: Objectives To evaluate the ability of clinical and radiographic features to predict lymph node (pN1) disease among patients with renal cell carcinoma (RCC) undergoing nephrectomy, and to develop a preoperative risk prediction model. Patients and Methods 220 patients with preoperative computed tomography (CT) scans available for review underwent radical nephrectomy with lymph node dissection (LND) from 2000‐2010. Radiographic features were assessed by one genitourinary radiologist blinded to pN status. Associations of features with pN1 disease were evaluated using logistic regression to develop predictive models. Model performance was assessed using AUC and decision curve analysis. Results Median lymph node yield was 10 (IQR 5‐18). Fifty‐five (25%) patients had pN1 disease at nephrectomy. On univariable analysis, maximum lymph node (LN) short axis diameter (OR 1.17; p
      PubDate: 2016-02-23T07:17:29.603251-05:
      DOI: 10.1111/bju.13424
  • A prospective study of the short‐term quality of life outcomes of
           patients undergoing transperineal prostate biopsy
    • Authors: Adam S. Dowrick; Addie C. Wootten, Nicholas Howard, Justin S. Peters, Declan G. Murphy
      Abstract: A prospective, observational study to investigate whether transperineal prostate biopsy (TPbx) results in patient‐reported quality of life changes from baseline in the first three‐months after the procedure. Patients and methods Consenting patients completed the Expanded Prostate cancer Index Composite (EPIC‐26), the Sexual Health Inventory for Men (SHIM), the International Prostate Symptom Score (IPSS), the Generalised Anxiety Disorder (GAD‐7), the Patient Health Questionnaire (PHQ‐9) and a global question about willingness to have a repeat TPbx in a years’ time. The instruments were scored using published scoring methods. Wilcoxon signed ranks tests and Mann‐Whitney U tests were used to investigate statistically significant differences. Clinically significant differences were also investigated defined by published minimal important differences for the EPIC and changes in established categorical groups for the other instruments. Results Fifty‐three participants consented to participate and completed the baseline questionnaire in addition to at least one of the 1‐ or 3‐month follow‐up questionnaires. We found that most patients having a TPbx had no clinically significant change in quality of life in the first three months following the procedure. However, 24% exhibited clinically worse urinary function and 18% had worse sexual function at one‐month. At three‐months, 3% of patients had clinically worse urinary function and 25% continued to have worse sexual function compared with baseline. Patients who were subsequently diagnosed with cancer on the basis of the results of the TPbx exhibited statistically significantly reduced quality of life for the EPIC urinary scales and reduced improvements in scores on the psychological scales at one‐month follow‐up compared with those who were not diagnosed with cancer. Conclusions Most patients having a TPbx had no clinically significant change in quality of life in the first three months following the procedure. However, patients should be advised that a quarter may have clinically worse urinary function and nearly 20% have clinically worse sexual function in the first month and that sexual function deficits may continue up to three‐months. The results of this study provide a resource that the clinician can use when discussing TPbx with patients. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-23T07:04:04.542696-05:
      DOI: 10.1111/bju.13413
  • MicroRNA‐30a as a prognostic factor in Urothelial Carcinoma of
           Bladder inhibits cellular malignancy by antagonizing Notch1
    • Authors: Chao Zhang; Xin Ma, Jun Du, Zhiyong Yao, Taoping Shi, Qing Ai, Xusheng Chen, Zhenting Zhang, Xu Zhang, Xin Yao
      Abstract: Objective To explore the relation between miR‐30a and Notch1 and to evaluate the potential prognostic role of miR‐30a in invasive urothelial carcinoma of bladder (UCB). Patients and methods Fifty invasive urothelial carcinoma of bladder (UCB) tissue specimens, along with the adjacent bladder tissue specimens were obtained and clinical parameters of the fifty patients were analyzed. Bioinformatics analysis was performed and microRNA‐30a (miRNA‐30a/ miR‐30a) was selected as a potential miRNA targeting Notch1 and luciferase assay was performed to verify the binding site between miR‐30a and Notch1. Quantitative real‐time PCR (qRT‐PCR) was conducted to assess the RNA expressions of miR‐30a and Notch1, while western blotting and immunohistochemical staining were carried out to assess the protein expression of Notch1. Finally, cell proliferation, cell cycle, cell migration and invasion assays were conducted to evaluate the cellular effects of miR‐30a and Notch1 on UCB cell lines T24 and 5637. Results MiR‐30a was downregulated in tumour tissues when compared with adjacent bladder tissues (P
      PubDate: 2016-02-21T23:52:04.861617-05:
      DOI: 10.1111/bju.13407
  • Ambulatory Movements, Team Dynamics and Interactions during
           Robot‐Assisted Surgery
    • Authors: Nabeeha Ahmad; Ahmed A. Hussein, Lora Cavuoto, Mohamed Sharif, Jenna C. Allers, Nobuyuki Hinata, Basel Ahmad, Justen D. Kozlowski, Zishan Hashmi, Ann Bisantz, Khurshid A. Guru
      Abstract: Objective To analyze ambulatory movements and team dynamics during robot‐assisted surgery (RAS), and investigate whether congestion of the physical space associated with RA technology led to workflow challenges, or predisposed to errors and adverse events. Methods With IRB approval, we retrospectively reviewed 10 recorded RA radical prostatectomies in a single operating room (OR). OR was divided into 8 zones, and all movement were tracked and described in terms of start and end zones, duration, personnel, and purpose. Movement were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure). Results Mean operative time was 166 minutes, of which ambulation constituted 27 minutes (16%). A total of 2,896 ambulatory movements were identified (mean=290 ambulatory movements/procedure). Most of movements were procedure‐related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR (Figure 1); the heaviest traffic was between the Circulating Nurse Zone, Transit Zone and Supply‐1 Zone.Fifty percent of ambulatory movements were found to be avoidable. Conclusion More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence‐based OR layout that enhances access, workflow and patient safety. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-21T23:50:07.850675-05:
      DOI: 10.1111/bju.13426
  • Plasma fibrinogen level: An independent prognostic factor for
           disease‐free survival and cancer‐specific survival in patients
           with localized renal cell carcinoma
    • Authors: Jun Obata; Nobuyuki Tanaka, Ryuichi Mizuno, Kent Kanao, Shuji Mikami, Kazuhiro Matsumoto, Takeo Kosaka, Eiji Kikuchi, Masahiro Jinzaki, Mototsugu Oya
      Abstract: Objectives To investigate the impact of perioperative plasma fibrinogen level as a biomarker of oncological outcome in localized renal cell carcinoma (RCC). Methods We consecutively identified 601 localized RCC patients who underwent curative surgery at a single institution. Subsequent disease recurrence and cancer‐specific survival were assessed using the Kaplan–Meier method. To evaluate the independent prognostic impact of plasma fibrinogen level, multivariate analysis was performed for these outcomes. Results Using the defined cut‐off level of preoperative plasma fibrinogen ≥420 mg/dL as elevated, we found 56 patients (9.3%) with an elevated plasma fibrinogen level preoperatively. In Kaplan–Meier analysis, there was a significant difference in disease‐free and cancer‐specific survival rates between patients with and without preoperative plasma fibrinogen levels ≥420 mg/dL. Multivariate analysis showed that elevated preoperative plasma fibrinogen level was an independent predictor of subsequent disease recurrence and cancer‐specific mortality. In a subgroup analysis of the elevated preoperative plasma fibrinogen level group, postoperative normalization of plasma fibrinogen level was significantly associated with cancer‐specific survival, showing that patients with non‐normalized plasma fibrinogen levels tended to have a higher incidence of cancer‐specific mortality after surgery. Conclusion Patients with elevated preoperative plasma fibrinogen levels could be significantly predicted to have subsequent tumor metastasis and cancer‐specific mortality, while there was a significant difference in cancer‐specific survival between patients in the normalized and non‐normalized postoperative plasma fibrinogen groups. While these are hypothesis generating results, plasma fibrinogen levels may be a useful biomarker, due to its low cost and ease of assessment. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-19T03:31:51.202232-05:
      DOI: 10.1111/bju.13414
  • Phase II Trial of Docetaxel, Bevacizumab, Lenalidomide, and Prednisone in
           Patients With Metastatic Castration‐Resistant Prostate Cancer
    • Abstract: Objective To determine the safety and clinical efficacy of two anti‐angiogenic agents, bevacizumab and lenalidomide, with docetaxel and prednisone. Preclinical data have demonstrated the importance of angiogenesis in prostate cancer, but previous clinical trials using angiogenesis inhibitors in combination with docetaxel have not established clinical benefit. The use of multiple anti‐angiogenic therapies together may suppress resistance mechanisms and optimize this therapeutic strategy. Subjects and Methods Eligible patients with metastatic castration‐resistant prostate cancer enrolled in this open label, phase II study of lenalidomide with bevacizumab (15 mg/kg), docetaxel (75 mg/m2) and prednisone (10mg daily). Docetaxel and bevacizumab were administered on day 1 of a 3‐week treatment cycle. To establish safety, lenalidomide dosing in this combination was escalated in a conventional 3+3 design (15, 20 and 25mg daily for two weeks followed by one week off). Patients received supportive measures including prophylactic pegfilgrastim and enoxaparin. The primary objectives were safety and clinical efficacy. Results Sixty‐three patients enrolled in this trial. Toxicities were manageable with most common adverse events being hematologic ascertained by weekly blood counts. Twenty‐nine patients (46%) had grade 4 neutropenia, 20 (32%) had grade 3 anemia and 7 (11%) had grade 3 thrombocytopenia. Despite frequent neutropenia, serious infections were rare. Other common non‐hematologic grade 3 adverse events include fatigue (10%) and diarrhea (10%). Grade 2 adverse events in >10% of patients included anorexia, weight loss, constipation, osteonecrosis of the jaw, rash and dyspnea. Of 61 evaluable patients, 57 (93%), 55(90%), and 33(54%) had PSA declines >30%, >50%, and >90% respectively. Twenty‐four of 29 patients (86%) had a confirmed radiographic partial response. The median time to progression and overall survival were 18.2 and 24.6 months, respectively. Conclusion With appropriate supportive measures, combination angiogenesis inhibition can be safely administered and potentially provide clinical benefit. This hypothesis generating data would require randomized trials to confirm these findings. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-19T03:28:38.524212-05:
      DOI: 10.1111/bju.13412
  • Accurately Determining Patients Who Underwent Robot‐Assisted
           Surgery: Limitations Of Administrative Databases
    • Abstract: The comparative effectiveness of open vs. robot‐assisted radical prostatectomy for prostate cancer remains a controversial debate in urology. Its evaluation has largely relied on observational studies using administrative claims. In this report, we compare the accuracy of ICD‐9 procedure codes vs. an itemized charge description methodology before and after the introduction of an ICD‐9 code specifically identifying RARP in October 2008. We find that prior to 2008, charge description and ICD‐9 procedures codes were poorly correlated, whereas after 2008, they were highly correlated. These findings call for a cautious interpretation of comparative effectiveness studies of ORP vs. RARP relying on ICD‐9 procedures codes, particularly before October 2008. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-18T08:11:54.675174-05:
      DOI: 10.1111/bju.13423
  • Hypospadias Repair with Onlay Preputial Graft: A 25‐year experience
           with long‐term follow‐up
    • Authors: Gina M. Cambareri; Michael Yap, George W. Kaplan
      Abstract: Objective To evaluate the long‐term outcomes of hypospadias repair utilizing an onlay preputial graft. Material and Methods Patient records from 1989‐2013 were retrospectively reviewed. A single surgeon performed all cases and surgical technique was the same for all patients. Results There were 62 patients in the cohort and average follow‐up was 47.4 (range 1‐185) months. The meatal location was separated into distal (1 patient), midshaft (19) and proximal (42). A total of 22 (35.5%) patients experienced complications. There were three main types of complications, including meatal stenosis in 3 (4.8%), stricture in 3 (4.8%) and fistula in 21 (33.9%). The average timing of presentation with a complication after surgery was 24.9 (range 1‐127) months. 54.5% of the patients with complications presented 12 months or more after the initial surgery and 31.8% of the patients with complications presented 3 or more years from the surgical date. On univariable analysis age at the time of surgery, length of the graft, presence of chordee or meatal location (proximal or midshaft) did not predict a complication. The width of the graft was associated with a complication, with each 1 mm increase in width decreasing the odds of a complication by 56%. On multivariable analysis width remained statistically significant (OR 0.44, 95%CI 0.230‐0.840, p=0.013) for predicting a complication. Conclusion Hypospadias repair with onlay preputial graft is an option for single stage repair, especially in cases of proximal hypospadias or where the urethral plate width and/or the glanular groove is insufficient for other types of repair. Compared to flaps, the use of grafts may decrease the risk of penile torsion and prevent less bulk around the urethra, improving skin and glans closure. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-17T22:20:59.762031-05:
      DOI: 10.1111/bju.13419
  • The incidence and sequela of lymphocele formation after
           robot‐assisted extended pelvic lymph node dissection
    • Abstract: Objective To reveal an accurate incidence of lymphocele formation and its sequela following robot‐assisted radical prostatectomy and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort. Patients and Method Consecutive patients who underwent radical prostatectomy and eLND with robot‐assistance and had a minimum follow‐up of 3 months were included. All surgeries were performed by one surgeon through a transperitoneal approach, with patients uniformly receiving low molecular weight heparin. Patients were followed with serial ultrasound imagings based on a predetermined schedule for lymphocele surveillance. Incidence and sequela of lymphoceles were retrospectively assessed. Results A total of 521 patients were analyzed. Follow‐up after surgery was 33.5 ± 22.8 months. Lymphocele developed in 9% and became symptomatic in 2.5%. All except one were detected on 1st month imaging; however, 76% regressed at 3‐month ultrasound. If lymphocele persisted at 3 months, 64% developed symptoms associated with infection and required drainage. Having diabetes mellitus was significantly associated with a higher risk of developing infected lymphocele. Other symptoms related to lymphocele were rare. Comparisons of patient characteristics between patients with and without lymphoceles did not demonstrate any significant prognostic indicators to predict the occurrence of lymphocele in neither univariate nor multivariate analysis in the present cohort. Conclusion The incidence of symptomatic lymphocele after robot‐assisted transperitoneal radical prostatectomy and eLND is rare. Obtaining an US imaging at 3 months after surgery seems feasible. Once a lymphocele is detected on 3 monthly US, discussing percutaneous external drainage with the patient appears to be wise, since it may prevent the development of symptomatic lymphocele in 2/3 of the patients. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-17T08:46:12.242565-05:
      DOI: 10.1111/bju.13425
  • Percutaneous Nephrolithotomy for Staghorn Stones: A Randomized Trial
           Comparing High Power Holmium Laser versus Ultrasonic Lithotripsy
    • Abstract: Objective To compare high power holmium Laser lithotripsy (HP‐HLL) and ultrasonic lithotripsy (US‐L) in disintegration of staghorn stones during percutaneous nephrolithotomy (PNL). Patients and Methods A non‐inferiority randomized controlled trial was conducted between August 2011 and September 2014. Inclusion criteria were patients’ age >18 years who had complete staghorn stones (branching to the three major calyces) without contraindications to PNL. Eligible patients were randomized between 2 groups (HP‐HLL and US‐L). A Standard PNL in prone position was performed for all patients. The only difference between treatment groups was method of stone disintegration. In the first group, Laser power of 40‐60 Watt (2 Joules, 20‐30 Hertz) was used to pulverize the staghorn stone into very small fragments that can pass through the Amplatz sheath with the irrigation fluid. Ultrasonic lithotripsy with suction of the fragments was used in the second group. The primary outcome (stone‐free rate) was evaluated with non‐contrast CT after 3 months. Secondary outcomes; complication, blood transfusion, operative time and haemoglobin deficit were compared. Outcome assessor was blinded to the treatment arm. Results The study included 70 patients (35 in each group). The base line characters (age, sex, BMI, side, stone volume and density) and operative technique (number, size of tracts and need for second PNL session) were comparable for both groups. Operative time was significantly shorter in US‐L (130+34 versus 148.7+35 minutes, P=0.028). Mean hemoglobin deficit was significantly more with US‐L (1.7+0.9 versus 1.3+0.6, P=0.037). The differences in blood transfusion (17% in US‐L versus 11% for HP‐HLL) and the complication rates (34% US‐L versus 23% HP‐HLL) were not significant (P=0.495 and 0.290 respectively). The stone‐free rates at 3 months were comparable (60% for US‐L and 66% for HPL‐L, P=0.621). Conclusions Compared with US‐L for intracorporeal lithotripsy of staghorn stone during PNL, HP‐HLL showed comparable safety and efficacy with lower hemoglobin deficit but longer operative time. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-16T00:04:00.27772-05:0
      DOI: 10.1111/bju.13418
  • Ninety‐Day Postoperative Mortality after Robot‐assisted
           Laparoscopic Prostatectomy and Retropubic Radical Prostatectomy.
           Nation‐wide population‐based study
    • Abstract: Objective To assess 90‐day postoperative mortality after Robot assisted laparoscopic Radical prostatectomy (RARP) and retropubic radical prostatectomy (RRP) by use of nationwide population‐based registry data. Patients and methods Cohort study in the National Prostate Cancer Register (NPCR) of Sweden of 22 344 men with prostate cancer in clinical local stage T1‐T3, PSA
      PubDate: 2016-02-15T23:52:53.580989-05:
      DOI: 10.1111/bju.13404
  • Initial experience of an algorithm‐based protocol for the community
           follow‐up of men with prostate cancer
    • Authors: Philip P Goodall; Jessica Little, Eleanor Robinson, Ian Trimble, Owen J Cole, Thomas J Walton
      Abstract: Objectives To evaluate the implementation of a novel algorithm‐based discharge programme for the community follow‐up of men with prostate cancer. Patients and methods Men with prostate cancer considered suitable for discharge were identified from consultant‐led and clinical nurse specialist telephone clinics at Nottingham University Hospitals NHS Trust. Patients were discharged on to one of four discharge pathways: watchful waiting, androgen deprivation therapy (ADT), post‐prostatectomy and post‐radiotherapy. Primary care providers were asked to adhere to specific surveillance measures and refer patients back to secondary care following breach of pre‐defined PSA threshold criteria. Reasons for non‐compliance, re‐referral and cause of death were determined for all discharged men. Findings 573 men were discharged across all four pathways; 169 on the watchful waiting pathway, 229 on the ADT pathway, 95 on the post‐prostatectomy and 80 on the post‐radiotherapy pathway. All patients had a minimum 12 months follow‐up. 48 of 54 (88.9%) of men were re‐referred promptly following PSA‐threshold breach. Of the remaining six patients there were three refusals, one unrelated death prior to referral and two late referrals at four months. Three patients were lost to follow‐up due to database non‐registration and were subsequently recalled, none of whom with a PSA‐threshold breach. There were three unexpected deaths attributed to prostate cancer: two were community deaths with no biochemical or clinical evidence of prostate cancer progression; one was due to a likely progressive PSA non‐secreting tumour. Interpretation Initial results suggest the algorithm‐based protocol is a viable, effective and oncologically safe method for the controlled discharge of men from secondary to primary care. Longer‐term follow‐up, patient satisfaction and cost‐effectiveness data are required to assess the true impact of the initiative. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-15T22:56:57.509248-05:
      DOI: 10.1111/bju.13446
  • Oncologic and functional outcomes one year after radical prostatectomy for
           very low risk prostate cancer. Results from the prospective LAPPRO trial
    • Abstract: Objectives To analyse oncological and functional outcomes 12 months after treatment of very low risk prostate cancer with radical prostatectomy in men who could have been candidates for active surveillance. Patients and Methods A prospective study of all men with very low risk prostate cancer who underwent radical prostatectomy at 14 participating centres. Validated patient questionnaires were collected at base line and after 12 months by independent health‐care researchers. Biochemical recurrence (BCR) was defined as PSA ≥ 0.25 ng/ml or treatment with salvage radiotherapy or treated with hormones. Urinary continence was defined as “less than one pad changed per 24 hour”. Erectile function was defined as “erection hard enough for penetration more than half of the time after sexual stimulation”. Changes in tumor grade and stage were obtained from pathology reports. We show descriptive frequencies and proportions having each outcome in various subgroups. Fisher's exact test was used to assess differences between the age groups. Results Of the 4003 men in the LAPPRO cohort, 338 men fulfilled the preoperative national criteria for very low risk prostate cancer. Adverse pathology outcomes included: upgrading, defined as pT3 or postoperative Gleason sum ≥ 7, was present in 35% (115/333), positive surgical margins, 16% (54/329). Only 7/329 men (2.1%) had PSA concentration > 0.1 ng/ml 6‐12 weeks postoperatively. Erectile function and urinary continence were 44% (98/222) and 84% (264/315) 12 months postoperatively. Trifecta defined as preoperative potent and continent men that remained potent and continent with no BCR was at 12 months 38% (84/221). Conclusions Our prospective study of men with very low risk prostate cancer undergoing open or robotic radical prostatectomy showed favourable oncological outcome in about two‐thirds. About 40 per cent did not suffer from surgically induced urinary incontinence or erectile dysfunction 12 months postoperatively. These results provide additional support for the use of active surveillance in men with very low risk prostate cancer, however the group of men with risk of upgrading and upstaging is not negligible. Improved stratification is still an urgently needed. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-11T07:26:59.149876-05:
      DOI: 10.1111/bju.13444
  • Technical Mentorship during Robot‐Assisted Surgery: A Cognitive
    • Authors: Ahmed A. Hussein; Somayeh B. Shafiei, Mohamed Sharif, Ehsan Esfahani, Basel Ahmad, Justen D. Kozlowski, Zishan Hashmi, Khurshid A. Guru
      Abstract: Objective To investigate the role of cognitive and mental workload assessment may play a critical role in defining successful mentorship Materials and Methods “Mind Maps” project aims at evaluating cognitive function of surgeon's expertise and trainee's skills. The study included electroencephalogram (EEG) recordings of the mentor observing trainee surgeons in 20 procedures during extended lymph node dissection (e‐LND) and urethro‐vesical anastomosis (UVA), with simultaneous assessment of trainees using NASA‐TLX questionnaire. We also compared the brain activity of the mentor during this study to his own brain activity while actually performing the same surgical steps from previous procedures populated in the “Mind Maps” project.. Results During LND and UVA, when the mentor thought the trainee's mental demand and effort were low based on his NASA‐TLX (not satisfied with his performance), his EEG‐based mental workload increased (reflecting more concern and attention). The mentor was mentally engaged and concerned while he was engrossed in observing the surgery. This was further supported by the finding that there was no significant difference in the mental demands and workload between observing and operating for the expert surgeon. Conclusion This study objectively evaluated cognitive engagement of a surgical mentor teaching technical skills during surgery. Our study provides a deeper understanding of how surgical teaching actually works and opens new horizons for assessment and teaching of surgery. Further research is needed to study the feasibility of this novel concept in assessment and guidance of surgical performance. This article is protected by copyright. All rights reserved.
      PubDate: 2016-02-11T05:14:26.131408-05:
      DOI: 10.1111/bju.13445
  • Admissions to hospital due to fracture in England in prostate cancer
           patients treated with Androgen Deprivation Therapy (ADT) – do we
           have to worry about the hormones'
    • Authors: E R Jefferies; A Bahl, L Hounsome, M F Eylert, J Verne, R A Persad,
      Abstract: Objective To investigate the relationship effect of androgen deprivation therapy (ADT) and fracture in men in the UK. Patients and Methods Using the Hospital Episodes Statistics (HES) database for years 2004 to 2008 that contains all the information about NHS and NHS‐funded hospital admissions in England ‐ 8,902 patients were found to have had prostate cancer and an admission to hospital with a fracture in 2004 to 2008. Of these 3,372 (37.8%) were flagged as being treated with ADT, whilst there were 5,530 (62.2%) admissions in the non ADT group (table 1). There were a total number of 228,852 admissions in the background population. Results The risk of a fracture requiring hospitalisation increases from 1.12 to 1.41 per 100 person years when a man is treated with ADT with prostate cancer than without – an absolute increase of only 0.29 per 100 person years. When compared to the background population, there is an increase from 0.58 per 100 person years in the background population to 1.41 – a relative rate ratio increase of 2.4 (p
      PubDate: 2016-02-06T05:26:26.33865-05:0
      DOI: 10.1111/bju.13441
  • Clostridium Histolyticum Collagenase – Is this revolutionary medical
           treatment for Peyronie's disease'
    • Authors: C Poullis; M Shabbir, I Eardley, J Mulhall, S Minhas
      Abstract: Peyronie's disease was described by Francois de la Peyronie in 1743, a battlefield surgeon and Commander of the Medical Corps of Louis XIV. The prevalence in the general population varies from 0.39‐3.4%, but increases to 7.1% in patients between 50‐69 years of age, with a reported prevalence rate of 20.3% in men with diabetes. The disease has two distinct clinical phases; the acute and stable or chronic phases. The acute phase is characterised by painful erections with increasing penile deformity usually lasting between 3‐12 months. The chronic phase is usually pain‐free and characterised by stabilisation of the plaque and penile deformity. The aetio‐pathogenesis of the disease remains largely unknown with local trauma, genetic and vascular factors being implicated. This article is protected by copyright. All rights reserved.
      PubDate: 2015-12-18T12:51:49.335433-05:
      DOI: 10.1111/bju.13396
  • Prospective Evaluation of 68Gallium‐PSMA Positron Emission
           Tomography/Computerized Tomography for Preoperative Lymph Node Staging in
           Prostate Cancer
    • Abstract: Objectives Conventional imaging techniques are inadequate for lymph node staging in prostate cancer (PC). This study aims to assess the accuracy of 68Ga‐PSMA positron emission tomography/computed tomography (PET/CT) for lymph node (LN) staging in intermediate and high‐risk PC. Materials and Methods From April to October 2015, 30 patients with intermediate (n=3) or high‐risk (n=27) PC were prospectively enrolled. Patients underwent preoperative 68Ga‐PSMA PET/CT. Both visual and semi quantitative analysis was undertaken. Subsequently, all patients underwent a radical prostatectomy with an extended pelvic lymph node dissection (eLND). Sensitivity, specificity, positive and negative predictive value (PPV and NPV) for LN status of 68Ga‐PSMA were calculated using histopathology as reference. Results Eleven patients (37%) had lymph node metastases (LNMs), 26 LNMs were identified in the 11 patients. On a patient analysis, 68Ga‐PSMA PET/CT has a sensitivity of 64% for the detection of LNMs, specificity was 95%, PPV was 88%, and NPV was 82%. In total, 180 LN fields were analyzed. For the LN‐region‐based analysis, the sensitivity of 68Ga‐PSMA PET/CT for detection of LNMs was 56%, specificity was 98%, PPV was 90% and NPV was 94%. Mean size of missed LNMs was 2.7mm. Receiver operating characteristic (ROC) analysis demonstrated high accuracy of SUV max for the detection of LNMs, AUC 0.915 (95%CI 0.847‐0.983); optimum SUV max was 2.0. Conclusions In patients with intermediate to high‐risk PC, 68Ga‐PSMA PET/CT has a high specificity and a moderate sensitivity for LNM detection. 68Ga‐PSMA PET/CT has the potential to replace current imaging for LN staging of patients with PC scheduled for radical prostatectomy. This article is protected by copyright. All rights reserved.
  • Active surveillance for low‐risk Non‐Muscle Invasive Bladder
           Cancer (NMIBC): mid‐term results from a Bladder cancer Italian
           Active Surveillance (BIAS) project
    • Abstract: Objective To report the oncologic safety and the risk of progression for patients with NMIBC included in an active surveillance (AS) program after the diagnosis of recurrence. Subjects and methods This is a prospective study enrolling patients with history of pathologically confirmed LG pTa‐pT1a Non‐Muscle Invasive Bladder Cancer (NMIBC) and diagnosed with a tumour recurrence. Inclusion criteria consisted of negative urine cytology, presence of ≤ 5 NMIBCs with a diameter ≤ 10 mm, absence of carcinoma in situ (CIS) or persistent gross haematuria. The primary outcome of interest was adherence to AS. Need to proceed with treatment was defined as progression in number/dimension/positive cytology/symptoms (gross haematuria persistent) or any further intervention (resection or electro‐fulguration). Finally, we assessed the up‐grading and up‐staging when transurethral resection of bladder tumour (TURBT) was performed. Results The study population consisted of 55 patients with a previous diagnosis of NMIBC (70 active surveillance events) prospectively recruited since 2008. The mean patient age was 69.8 years. Median follow‐up was 53 months. The median time patients remained under AS was 12.5 months. A disease progression was observed in 28 patients (51%). No patient experienced progression to muscle‐invasive disease. Fifteen patients (27.3%) showed an increase in the number and/or size of the tumour, 9 (16,4%) suffered from hematuria and 4 (7.3%) had a positive cytology. Only 5 (9%) patients in the whole series experienced progression to a high‐ grade tumour (G3) or presented with associated CIS. The overall adherence to the follow‐up schedule was 95%. Conclusion Our data showed that an AS protocol for NMIBC could be a reasonable option in a selected group of patients with small, recurrent cancers. This article is protected by copyright. All rights reserved.
  • Robotic Assisted Partial Cystectomy (RAPC): perioperative outcomes and
           early oncologic efficacy
    • Abstract: Objective To report on patients undergoing robotic‐assisted partial cystectomy (RAPC), focusing on perioperative outcomes over a range of clinical, anatomic and pathologic variables as well as the overall oncological efficacy of this approach. Patients and Methods We retrospectively reviewed all patients who underwent robotic assisted partial cystectomy (RAPC) by a single surgeon between 2005‐2015. We identified 29 patients who underwent surgery for definitive management of a primary bladder tumor. Clinicopathologic data and perioperative variables were recorded. Continuous variables were compared using student's t‐test. Prediction of perioperative outcomes for those undergoing RAPC for intradiverticular neoplasms was done using univariable logistic regression. Survival was estimated using the Kaplan‐Meier method. Results Median patient age was 75 years [IQR 65‐81], 18 patients (62.1%) had an ASA classification of 3 or higher, and 10 patients (34.5%) had a history of prior abdominal surgery. Median blood loss was 50 cc and median length of stay was 1 day. Two patients (6.9%) experienced a perioperative complication and five (17.9%) a post‐discharge 90 day complication, all which were minor. Positive surgical margin rate was 3.6%, and in those with muscle invasive disease a median of 12 lymph nodes were removed. Neither size of diverticulum or need for ureteral reimplant were predictive of length of stay, blood loss, or complication (p>0.05). We did not encounter any wound, port site, or unusual recurrence patterns to suggest the technical factors of a robotic approach influenced oncologic outcomes. Five‐year overall and recurrence‐free survival rates were 79% and 68% respectively. Conclusion RAPC confers the ability to achieve favorable outcomes with low morbidity and reduced hospital stays. Oncological efficacy compares favorably with published literature. For experienced surgeons, this may represent the optimal surgical approach for organ preserving bladder surgery. This article is protected by copyright. All rights reserved.
  • A retrospective analysis of laparoscopic partial nephrectomy with
           segmental renal artery clamping and parameters that estimate postoperative
           renal function
    • Abstract: Objective To evaluate the feasibility and efficiency of laparoscopic partial nephrectomy (LPN) with segmental renal artery clamping, and to analyze the factors affecting postoperative renal function. Patients And Methods A retrospective analysis of 466 consecutive patients undergoing LPN using main renal artery clamping (Group A, n = 152) or segmental artery clamping (Group B, n = 314) from September 2007 to July 2015 in our department. Blood loss, operative time, warm ischemia (WI) time, and renal function were compared between groups. Univariable and multivariable linear regression analyses were applied to assess correlations of selected variables with postoperative glomerular filtration rate (GFR) reduction. Volumetric data and estimated glomerular filtration rate (eGFR) of a subset of 60 patients in Group B were compared with GFR to evaluate the correlation between these functional parameters in predicting preserved renal function after LPN. Results The novel technique slightly increased operative time, WI time and intraoperative blood loss (P < 0.001), while it provided better postoperative renal function (P < 0.001) compared with conventional technique. The blocking method and tumor characteristics were independent factors affecting GFR reduction, while WI time was not independent factors. Correlation analysis showed that eGFR presented better correlation with GFR compared with kidney volume (R2 = 0.794 cf. R2 = 0.199) in predicting renal function after PN.. Conclusions LPN with segmental artery clamping minimizes WI injury and provides for better early postoperative renal function compared with clamping the main renal artery. Kidney volume has a significantly inferior role compared with eGFR in predicting preserved renal function. This article is protected by copyright. All rights reserved.
  • Analysis of the sperm functional aspects and seminal plasma proteomic
           profile from male smokers
    • Abstract: Objective To evaluate the effect of smoking on sperm functional quality and seminal plasma proteomic profile. Patients And Methods Sperm functional tests were performed in 20 nonsmoking men with normal semen quality, according to the World Health Organization (2010) and in 20 smoking patients: evaluation of DNA fragmentation by alkaline Comet assay; analysis of mitochondrial activity using DAB staining; and acrosomal integrity evaluation by PNA binding. Remaining semen was centrifuged and seminal plasma was utilized for proteomic analysis (LC‐MS/MS). The quantified proteins were used in Cytoscape 3.2.1 software for Venn diagrams construction, using the PINA4MS plugin. Then, differentially expressed proteins were also used for functional enrichment analysis of Gene Ontology categories, Kyoto Encyclopedia of Genes and Genomes and Reactome, using the Cytoscape software and the ClueGO 2.2.0 plugin. Results Smokers presented higher percentage of sperm DNA damage (Comet classes III and IV, p
  • Comparison of prostate cancer survival in Germany and the United States:
           Can differences be attributed to differences in stage distributions'
    • Abstract: Objectives To better understand influence of prostate‐specific antigen (PSA) screening and other health system determinants on prognosis of prostate cancer (PCa), up‐to‐date relative survival (RS), stage distributions, and trends in survival and incidence in Germany were evaluated and compared with the United States (US). Patients and Methods Incidence and mortality rates for Germany and the US for the period 1999 to 2010 were obtained from the Center for Cancer Registry Data at the Robert Koch Institute and the US Surveillance Epidemiology and End Results (SEER) database. For analyses on stage and survival, data from 12 population‐based cancer registries in Germany and from the SEER‐13 database were analyzed. Patients (≥15 years) diagnosed with PCa (1997‐2010), with mortality follow‐up to December 2010 were included. 5‐ and 10‐year RS and survival trends (2002‐2010) were calculated using standard and model‐based period analysis. Results Between 1999 and 2010, PCa incidence decreased in the US but increased in Germany. Nevertheless incidence remained higher in the US throughout the study period (99.8 vs. 76.0 per 100,000 in 2010). The proportion of localized disease significantly increased from 51.9% (1998‐2000) to 69.6% (2007‐2010) in Germany and from 80.5% (1998‐2000) to 82.6% (2007‐2010) in the US. Mortality slightly decreased in both countries (1999‐2010). Overall, 5‐ and 10‐year RS was lower in Germany (93.3%; 90.7%) than in the US (99.4%; 99.6%) but comparable after adjustment for stage. The same patterns were observed in age‐specific analyses. Improvements observed in PCa survival between 2002‐2004 and 2008‐2010 (5‐year RS: 87.4; 91.2; +3.8% units) disappeared after adjustment for stage (p=0.8). Conclusion The survival increase in Germany and the survival advantage in the US might be explained by differences in incidence and stage distributions over time and across countries. Effects of early detection or a lead time bias due to the more widespread utilization and earlier introduction of PSA testing in the US are likely to explain the observed patterns. This article is protected by copyright. All rights reserved.
  • Wound dehiscence in a sample of 1 776 cystectomies: identification of
           predictors and implications for outcomes
    • Abstract: Objective To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC). Patients and Methods In all, 1 776 patient records with Current Procedural Terminology (CPT) codes for radical cystectomy (RC) were extracted from the American College of Surgeons National Quality Improvement Program (ACS‐NSQIP) between 2005 and 2012. Stratification was made based on the occurrence of postoperative wound dehiscence, defined as loss of integrity of fascial closure. Descriptive and logistic regression models were used to identify predictors of postoperative wound dehiscence. The implications of wound dehiscence on peri‐ and postoperative outcomes such as complications, mortality, prolonged length of stay (>11 days), and prolonged operative time (>411 min), were assessed. Results Of 1 776 patients analysed, 57 (3.2%) had a documented wound dehiscence. In multivariable analyses, chronic obstructive pulmonary disease (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.0–4.0; P = 0.03) and high body mass index (OR 2.3, 95% CI 1.3–4.4; P = 0.008) were significant predictors of wound dehiscence. While female gender had significantly lower proportions of wound dehiscence, multivariable analyses did not confirm this (OR 0.4, 95% CI 0.4–1.4; P = 0.75). Conclusions Our study is the first to identify predictors of wound dehiscence after RC in a large, contemporary multi‐institutional cohort. Identifying patients at risk of postoperative wound complications may guide the use of preventative measures at the time of surgery.
  • Risk factors for recurrence after surgery in non‐metastatic RCC with
           thrombus: a contemporary multicentre analysis
    • Abstract: Objective To determine the predictors of post‐surgical recurrence for patients with non‐metastatic renal cell carcinoma (RCC) and venous thrombus. Methods Records from consecutive patients with non‐metastatic RCC with tumour thrombus, treated surgically between 2000 and 2012 at one of three centres, were reviewed. Univariable and multivariable analysis were used to evaluate the association of risk factors for post‐surgical recurrence. Results A total of 465 patients with non‐metastatic RCC were identified, including patients with thrombus present in the renal vein (257 patients, 55.3%), infrahepatic inferior vena cava (IVC; 144 patients, 31.0%) and suprahepatic IVC (64 patients, 13.8%). The median (interquartile range) follow‐up was 28.3 (12.2–56.4) months, with metastatic RCC developing in 188 patients (40.5%). Independent predictors of recurrence included: body mass index ≤20 kg/m2 (hazard ratio [HR] 2.66; 95% confidence interval [CI] 1.29–5.49), low preoperative haemoglobin (HR 1.54; 95% CI 1.07–2.20), perinephric fat invasion (HR 1.51; 95% CI 1.09–2.10), IVC thrombus height (HR 2.64; 95% CI 1.47–4.74), tumour diameter (HR 1.04 95% CI 1.00–1.09), nuclear grade (HR 1.56 95% CI 1.12–2.15) and non‐clear‐cell histology (HR 2.13; 95% CI 1.30–3.50). Independently predictive variables were used to create a recurrence model for three risk groups based on 0, 1–2, or >2 risk factors, respectively. The 5‐year recurrence‐free survival rate was significantly different in patients with favourable‐risk (79.1%) compared with intermediate‐ (55.1%) or high‐risk (22.1%) disease (P < 0.001). Conclusions Seven risk factors for recurrence were identified for patients with non‐metastatic RCC with thrombus, which can be used to select patients who may benefit from increased surveillance or adjuvant therapy clinical trials.
  • Increased use of partial nephrectomy to treat high‐risk disease
    • Abstract: Objectives To evaluate partial nephrectomy (PN) use in patients at higher risk for clinical progression, using a large national database of American patients. Patients and Methods We performed a retrospective review of patients with cN0/cM0 renal cell carcinoma from 2003 to 2011 using the National Cancer Data Base. Our primary endpoint was PN use for high‐risk disease, defined as ≥1 adverse pathological features (APF), namely pT3 stage, high grade, or unfavourable histology. Our secondary endpoint was positive surgical margins (PSM) associated with high‐risk disease after PN. Time trends were analysed using the asymptotic Cochran–Armitage trend test. Relationships between patient, provider, and pathological factors and the likelihood of PN were assessed using multivariate logistic regression. Results Of 183 886 surgically treated patients, 27.4% underwent PN. Over time, PN use increased overall (17.4–39.7%) and in tumours with ≥1 APF (8.5–24.2%) (P < 0.01). In patients with ≥1 APF, multivariate analysis revealed that academic practice setting and high surgical volume were positively associated with PN use, while increasing tumour size and preoperative biopsy were negatively associated with its use (P < 0.01). The PSM rate after PN also increased significantly over time in all patients and in those harbouring adverse pathology (P < 0.01). Aside from time, older age, larger tumour size, community hospital type, and robotic approach were associated with PSM in the setting of APF (P < 0.01). Conclusion PN use for patients with adverse pathology is increasing and is associated with increasing PSM. The long‐term oncological implications of these trends are unclear and warrant further study.
  • The impact of change in serum C‐reactive protein level on the
           prediction of effects of molecular targeted therapy in patients with
           metastatic renal cell carcinoma
    • Abstract: Objectives To investigate the impact of pretreatment serum C‐reactive protein (CRP) level and its change after targeted therapy on the anti‐tumour effect of targeted agents in patients with metastatic renal cell carcinoma (mRCC). Patients and Methods The serum CRP level in 190 cases of molecular targeted therapy for mRCC was measured before starting the prescription of molecular targeted agents and when computed tomography showed the maximum effect. Patients in which the pretreatment CRP level was ≥0.5 mg/dL were classified into a ‘higher‐CRP’ group and others into a ‘lower‐CRP’ group. The higher‐CRP group was further classified into two subgroups, i.e. those whose serum CRP level decreased after molecular targeted therapy (‘decreased‐CRP’ subgroup), and those whose level did not decrease after therapy (‘non‐decreased‐CRP’ subgroup). All patients were also classified according to their other clinical details and progression‐free survival (PFS) rates of each subgroup were compared. Results Of the 190 patients, 97 were categorised as lower CRP and 93 as higher CRP, with 50 and 43 patients in the higher‐CRP group further categorised as decreased‐ and non‐decreased‐CRP subgroups, respectively. For the maximum effects of the targeted therapy, determined based on the Response Evaluation Criteria In Solid Tumors (RECIST) criteria, in the lower‐CRP group, significantly more patients had a complete response (CR) and partial response (PR) (P = 0.002) and significantly fewer had progressive disease (PD) (P < 0.001) vs the higher‐CRP group. In the higher‐CRP group, significantly fewer patients had PD in the decreased‐CRP subgroup (P < 0.001) than those in the non‐decreased‐CRP subgroup. The 2‐year PFS rate for the lower‐CRP group (39.1%) was significantly better vs the decreased‐CRP subgroup (21.2%; P = 0.013) and significantly better vs the non‐decreased CRP subgroup (0%; P < 0.001). Multivariate analyses in the higher‐CRP group revealed that decreased CRP was an independent predictive factor for PFS (P = 0.002, hazard ratio 2.454, 95% confidence interval 1.404–4.290). Conclusion A decrease of CRP and pretreatment CRP levels show promise as a novel predictive factor for anti‐tumour effects in patients treated with molecular targeted therapy.
  • Population‐based study of long‐term functional outcomes after
           prostate cancer treatment
    • Abstract: Objective To evaluate long‐term urinary, sexual and bowel functional outcomes after prostate cancer treatment at a median (interquartile range) follow‐up of 12 (11–13) years. Patients and Methods In this nationwide, population‐based study, we identified 6 003 men diagnosed with localized prostate cancer (clinical local stage T1–2, any Gleason score, prostate‐specific antigen
  • Oncological control associated with surgical resection of isolated
           retroperitoneal lymph node recurrence of renal cell carcinoma
    • Abstract: Objective To evaluate the outcome of patients after surgical resection of isolated retroperitoneal lymph node (RPLN) recurrence of renal cell carcinoma (RCC) using a multicentre international cohort. Patients and Methods In all, 50 patients were identified who underwent resection of isolated RPLN recurrence of RCC at four institutions after nephrectomy for pTanyNanyM0 disease. Progression‐free (PFS) and cancer‐specific survival (CSS) were estimated using the Kaplan–Meier method. Cox proportional hazards regression models were used to assess the association of clinicopathological characteristics with disease progression. Results The median (interquartile range, IQR) age at resection was 57.0 (50.0–62.5) years. The median (IQR) time to RPLN recurrence after nephrectomy was 12.6 (6.9–39.5) months, with no significant difference in median time to RPLN recurrence between patients with N+ disease at nephrectomy (10.7 [6.5–24.6] months) and those with Nx/pN0 disease at nephrectomy (13.7 [8.7–44.2] months) (P = 0.66). The median (IQR) size of the RPLN recurrence before resection was 2.6 (1.9–5) cm. The most common site for RPLN recurrence was within the interaortocaval region (34%). The median (IQR) follow‐up after RPLN resection for patients alive at last follow‐up was 28.0 (13.7–51.2) months. During follow‐up, 26 patients developed RCC recurrence, at a median (IQR) of 9.9 (4.0–18.5) months after RPLN resection. Of those who developed a secondary recurrence, disease was again isolated to the retroperitoneum in seven patients. In all, 11 patients subsequently died, including 10 who died from disease. The median PFS after RPLN resection was 19.5 months, with a 3‐ and 5‐year PFS of 40.5% and 35.4%, respectively. We also found that RPLN recurrence at ≤12 months after nephrectomy was associated with a significantly inferior median PFS (12.3 months) compared with RPLN recurrence at >12 months after nephrectomy (47.6 months; P = 0.003). Moreover, on multivariate analysis, a shorter time to recurrence remained associated with a significantly increased risk for subsequent disease progression (hazard ratio 3.51; P = 0.005). Conclusion Surgical resection of isolated RPLN recurrence from RCC may result in durable cancer control in appropriately selected patients. Recurrence at ≤12 months after nephrectomy was associated with a significantly increased risk of progression after resection, underscoring the importance of this variable for risk stratification. Thus, we recommend that, in the setting of isolated RPLN recurrence of RCC (in patients without precluding comorbidities), careful consideration with the patients and medical oncology colleagues be undertaken about the relative and individualised benefits of surgical resection, systemic therapy, and surveillance.
  • Comparison of survival rates in stage 1 renal cell carcinoma between
           partial nephrectomy and radical nephrectomy patients according to age
           distribution: a propensity score matching study
    • Abstract: Objective To assess differences in overall survival (OS) between patients receiving partial nephrectomy (PN) and radical nephrectomy (RN) for stage 1 renal cell carcinoma (RCC) according to age distribution, as the survival advantage of PN vs RN has been unclear owing to conflicting data. Patients and Methods We studied 952 patients with stage 1 RCC who underwent either PN or RN. Patients were divided into three groups according to age: Group 1 (≤54 years), Group 2 (55–64 years), and Group 3 (≥65 years). Patient variables including age, body mass index, sex, presence of hypertension (HT) and/or diabetes mellitus (DM), performance status, tumour size, pathological diagnosis, nuclear grade, and preoperative estimated glomerular filtration rate (eGFR), were adjusted using 1:1 propensity score matching between PN and RN. Results Group 1 included 66 matched patients; Group 2, 72; and Group 3, 70. Group 1 tended to have higher preoperative eGFR values and lower rates of HT and DM compared with Groups 2 and 3. Postoperative eGFR dropped by 11–13% in PN patients and by 34–36% in RN patients. In Group 3, PN patients had longer OS than RN patients (5‐year OS: PN 96%, RN 81%, P = 0.043); however, there was no significant difference in Group 1 (5‐year OS: PN 100%, RN 93%, P = 0.302) or Group 2 (5‐year OS: PN 94%, RN 87%, P = 0.358). Conclusions Only the oldest group of patients showed significantly better OS for PN compared with RN; however, we still recommend PN in young patients.
  • Association between number of prostate biopsies and patient‐reported
           functional outcomes after radical prostatectomy: implications for active
           surveillance protocols
    • Abstract: Objectives To evaluate whether the number of preoperative prostate biopsies affects functional outcomes after radical prostatectomy (RP). Methods We identified patients treated with RP at our institution between 2008 and 2011. At 6 and 12 months postoperatively, the patients completed questionnaires assessing erectile and urinary function. Patients with preoperative incontinence or erectile dysfunction or who did not complete the questionnaire were excluded. Primary outcomes were urinary and erectile function at 12 months postoperatively. We used logistic regression to estimate the impact of number of prostate biopsies on functional outcomes after adjusting for demographic and clinical factors. Results We identified 2 712 patients treated with RP between 2008 and 2011. Most of the patients (80%) had one preoperative prostate biopsy, 16% had two, and 4% had at least three. On adjusted analysis, erectile function at 12 months was not significantly different for patients with two (odds ratio [OR] 1.25; 95% confidence interval [CI] 0.90, 1.75) or three or more (OR 1.52; 95% CI 0.84, 2.78) biopsies, compared with those with one biopsy. Similarly, urinary function at 12 months was not significantly different for patients with two (0.84, 95% CI 0.64, 1.10) or three or more (0.99, 95% CI 0.60, 1.61) biopsies compared with those with one. Conclusions We did not find evidence that a greater number of preoperative prostate biopsies adversely affected erectile or urinary function at 12 months after RP.
  • Physical activity as a risk factor for prostate cancer diagnosis: a
           prospective biopsy cohort analysis
    • Abstract: Objectives To assess the association between physical activity, evaluated by the Physical Activity Scale for the Elderly (PASE) questionnaire, and prostate cancer risk in a consecutive series of men undergoing prostate biopsy. Patients and Method From 2011 onwards, consecutive men undergoing 12‐core prostate biopsy were enrolled into a prospective database. Indications for a prostatic biopsy were a prostate‐specific antigen (PSA) value of ≥4 ng/mL and/or a positive digital rectal examination. Body mass index (BMI) and waist circumferences were measured before the biopsy. Fasting blood samples were collected before biopsy and tested for: total PSA, glucose, high‐density lipoprotein cholesterol, and trygliceride levels. Blood pressure was recorded. Metabolic syndrome (MetS) was defined according to the Adult Treatment panel III. The PASE questionnaire was completed before the biopsy. Results In all, 286 patients were enrolled with a median (interquartile range, IQR) age and PSA level of 68 (62–74) years and 6.1 (5–8.8) ng/mL, respectively. The median (IQR) BMI was 26.4 (24.6–29) kg/m2 and waist circumference was 102 (97–108) cm, with 75 patients (26%) presenting with MetS. In all, 106 patients (37%) had prostate cancer at biopsy. Patients with prostate cancer had higher PSA levels (median [IQR] 6.7 [5–10] vs 5.6 [4.8–8] ng/mL; P = 0.007) and lower LogPASE scores (median [IQR] 2.03 [1.82–2.18] vs 2.10 [1.92–2.29]; P = 0.005). On multivariate analysis, in addition to well‐recognised risk factors such as age, PSA level and prostate volume, LogPASE score was an independent risk factor for prostate cancer diagnosis (odds ratio [OR] 0.146, 95% confidence interval [CI] 0.037–0.577; P = 0.006]. LogPASE score was also an independent predictor of high‐grade cancer (OR 0.07, 95% CI 0.006–0.764; P = 0.029). Conclusion In our single‐centre study, increased physical activity, evaluated by the PASE questionnaire, is associated with a reduced risk of prostate cancer and of high‐grade prostate cancer at biopsy. Further studies should clarify the molecular pathways behind this association.
  • Risk of prostate cancer mortality in men with a history of prior cancer
    • Abstract: Objectives To describe outcomes of patients with prostate cancer diagnosed after another malignancy and identify factors associated with prostate cancer death in this population, as little is known about the clinical significance of prostate cancer as a subsequent malignancy. Patients and Methods We studied 18 225 men diagnosed with prostate cancer after another malignancy from 1973 to 2006. We compared demographic and clinical variables, and the proportion of death from prostate cancer vs prior malignancy with t‐test and chi‐squared analyses. Fine and Gray's regression was used to consider the effect of treatment on prostate cancer death. We then studied a second cohort of 88 013 men with prostate cancer as a first or second malignancy to describe current diagnostic and treatment patterns. Results One in seven men died from prostate cancer in our first cohort. More died from prostate cancer following colorectal cancer (16.8% vs 13.7%), melanoma (13.4% vs 7.56%), and oral cancer (19.1% vs 4.04%), but fewer following bladder cancer, kidney cancer, lung cancer, leukaemia and non‐Hodgkin's lymphoma (all P < 0.001). Prostate cancer treatment was associated with a nearly 50% lower risk of death when high‐grade or high‐stage (adjusted hazard ratio 0.55, 95% confidence interval [CI] 0.47–0.64). Patients who died from prostate cancer had higher grade and stage disease, and received less treatment than patients who died from prior malignancy. The second cohort showed subsequent prostate cancer had more high‐risk disease (36.3% vs 22.2%, P < 0.001) and less prostate cancer treatment (adjusted odds ratio 0.872, 95% CI 0.818–0.930) than primary prostate cancer. Conclusions Prostate cancer remains a significant cause of mortality when diagnosed as a subsequent cancer. These results suggest prostate cancer treatment should be seriously considered in patients with prior malignancies, especially those with high‐grade or locally advanced prostate cancer.
  • Symptoms, unmet needs, psychological well‐being and health status in
           survivors of prostate cancer: implications for redesigning follow‐up
    • Abstract: Objective To explore ongoing symptoms, unmet needs, psychological wellbeing, self‐efficacy and overall health status in survivors of prostate cancer. Patients and Methods An invitation to participate in a postal questionnaire survey was sent to 546 men, diagnosed with prostate cancer 9–24 months previously at two UK cancer centres. The study group comprised men who had been subject to a range of treatments: surgery, radiotherapy, hormone therapy and active surveillance. The questionnaire included measures of prostate‐related quality of life (Expanded Prostate cancer Index Composite 26‐item version, EPIC‐26); unmet needs (Supportive Care Needs Survey 34‐item version, SCNS‐SF34); anxiety and depression (Hospital Anxiety and Depression Scale, HADS), self‐efficacy (modified Self‐efficacy Scale), health status (EuroQol 5D, EQ‐5D) and satisfaction with care (questions developed for this study). A single reminder was sent to non‐responders after 3 weeks. Data were analysed by age, co‐morbidities, and treatment group. Results In all, 316 men completed questionnaires (64.1% response rate). Overall satisfaction with follow‐up care was high, but was lower for psychosocial than physical aspects of care. Urinary, bowel, and sexual functioning was reported as a moderate/big problem in the last month for 15.2% (n = 48), 5.1% (n = 16), and 36.5% (n = 105) men, respectively. The most commonly reported moderate/high unmet needs related to changes in sexual feelings/relationships, managing fear of recurrence/uncertainty, and concerns about the worries of significant others. It was found that 17% of men (51/307) reported potentially moderate‐to‐severe levels of anxiety and 10.2% (32/308) reported moderate‐to‐severe levels of depression. The presence of problematic side‐effects was associated with higher psychological morbidity, poorer self‐efficacy, greater unmet needs, and poorer overall health status. Conclusion While some men report relatively few problems after prostate cancer treatment, this study highlights important physical and psycho‐social issues for a significant minority of survivors of prostate cancer. Strategies for identifying those men with on‐going problems, alongside new interventions and models of care, tailored to individual needs, are needed to improve quality of life.
  • Issue Information
  • Evaluation and establishment of a ward‐based geriatric liaison
           service for older urological surgical patients: POPS‐Urology
           (Proactive Care of Older People Undergoing Surgery)
    • Abstract: Objective To assess the impact of introducing and embedding a structured geriatric liaison service, POPS‐Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward. Patients and Methods A phased quality improvement project was undertaken using stepwise interventions. Phase 1 ‐ A before‐and‐after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician‐led ward rounds for elective and emergency urology patients ≥65 years admitted over two one‐month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, 30‐day readmission and 30‐day mortality. Phase 2 ‐ A quality improvement project involving Plan‐Do‐Study‐Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist (GSCL) to: standardise the intervention in Phase 1, improve equity of care by extending to all ages, improve team working, and streamline handovers for multidisciplinary staff. Results Phase 1 ‐ 112 patients in the control month and 130 in the intervention month. Length of inpatient stay was reduced by 19% (mean 4.9 vs. 4.0 days, p=0.01), total postoperative complications were lower (RR 0.24 (0.10, 0.54), p=0.001). A non‐significant trend was seen towards fewer cancellations of surgery (10% vs. 5%, p=0.12) and 30‐day readmissions (8% vs. 3%, p=0.07). Phase 2 ‐ The GSCL was created and incrementally improved. Questionnaires repeated at intervals revealed the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers, and standardised identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen. Conclusion This is the first known paper describing benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focussed comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals in order to improve postoperative outcomes. This article is protected by copyright. All rights reserved.
  • Robotic‐assisted vs. open adrenalectomy: evaluation of cost
           effectiveness and perioperative outcome
    • Abstract: Objectives To compare Robotic assisted laparoscopic adrenalectomy (RALA) and open adrenalectomy (OA) with regard to intraoperative complications, perioperative outcome and cost effectiveness. Subjects/Patients And Methods Functional and statistical data from OA and RALA patients between 2001 and 2015 was prospectively recorded including intra‐ and post‐operative outcomes. We also utilized per‐day costs from current census reports (€540/d and €1145/d for normal and intermediate care) to evaluate treatment costs. Additional costs for RALA (€2288) were assumed in accordance with current literature. Patients were matched by ASA‐score, age, side of surgery and gender for comparison of OA and RALA. 28 matched pairs were analyzed for patient characteristics, perioperative outcomes and cost effectiveness. Statistical significance of outcome parameters were determined by student‐t‐test and Pearson's chi‐squared test. Results Due to the matching process, patient groups did not differ in their main characteristics. Length of stay was shorter for RALA (11.1 ± 4.8 vs. 6.8 ± 1.2 days, p
  • Redo‐buccal mucosa graft urethroplasty: Success rate, oral morbidity
           and functional outcome
    • Abstract: Objectives To determine success rate, oral morbidity and functional outcome of Redo‐buccal mucosa graft urethroplasty (BMGU) for treatment of stricture recurrence after prior BMGU. Patients and methods We included 50 Patients who underwent Redo‐BMGU between February 2009 and September 2014. Patients’ charts and non‐validated questionnaires were reviewed. Primary endpoint consisted of success rate defined as stricture‐free survival. Stricture recurrence was defined as any postoperative claims of catheterization, dilatation, urethrotomy or repeat urethroplasty or when maximum flow rate was
  • Budget impact of incorporating one instillation of hexaminolevulinate
           hydrochloride blue‐light cytoscopy in transurethral bladder tumour
           resection for patients with non‐muscle‐invasive bladder cancer
           in Sweden
    • Abstract: Objectives To explore the cost impact on Swedish healthcare of incorporating one instillation of hexaminolevulinate hydrochloride (HAL) blue‐light cystoscopy into transurethral resection of bladder tumour (TURBT) in patients with suspected new or recurrent non‐muscle‐invasive bladder cancer (NMIBC). Materials and Methods A decision tree model was built based on European Association of Urology guidelines for the treatment and management of NMIBC. Input data were compiled from two recent studies comparing recurrence rates of bladder cancer in patients undergoing TURBT with either the current standard of care (SOC) of white‐light cystoscopy, or with the SOC and HAL blue‐light cystoscopy. Using these published data with clinical cost data for surgical and outpatient procedures and pharmaceutical costs, the model reported on the clinical and economic differences associated with the two treatment options. Results This model demonstrates the significant clinical benefits likely to be observed through the incorporation of HAL blue‐light cystoscopy for TURBT in terms of reductions in recurrences of bladder cancer. Analysis of economic outputs of the model found that the use of one instillation of HAL for TURBT in all Swedish patients with NMIBC is likely to be cost‐neutral or cost‐saving over 5 years relative to the current SOC of white‐light cystoscopy. Conclusions The results of this analysis provide additional health economic rationale for the incorporation of a single instillation of HAL blue‐light cystoscopy for TURBT in the treatment of patients with NMIBC in Sweden.
  • Magnetic Resonance Microscopy May Enable Distinction Between Normal
           Histomorphological Features and Prostate Cancer in the Resected Prostate
    • Abstract: Introduction In vivo high‐resolution magnetic resonance imaging (MRI) at a microscopic level for the identification of prostate cancer (PCa) has not yet been achieved. This may be accomplished using MRI with high spatial resolution for ex vivo examination of prostate specimens. The objective was to determine imaging protocol parameters for characterization of prostate tissue at histologic length scales. Material and Methods Rapid acquisition with relaxation enhancement (RARE), spin echo (SE) and gradient echo (GRE) fast low angle shot (FLASH) data were acquired using ex vivo 3 Tesla or 7 Tesla magnetic field strengths from fresh prostatectomy specimens (n=15) obtained from either organ donor or PCa patients under Institutional Review Board approval. To achieve the closest correspondence between histopathological components and MRI images in terms of resolution and sectioning planes, multiple high resolution imaging protocols (ranging from few minutes to overnight) were tested. Ductograms were generated as part of image post‐processing. Specimens were subsequently submitted for histopathological evaluation. Results and Limitations A total of 7 imaging protocols were tested. Ex vivo 7 Tesla MRI identified normal components of prostate glands including ducts, blood vessels, concretions, and stroma at a spatial resolution of 60 X 60 X 60 μm3 to 107 X 107 X 500 μm3. Malignant glands and nests of tumor cells identified at 60 X 60 X 90 μm3 were highly comparable to low magnification (x2) histopathology. Ductograms enhanced the differentiation between benign and malignant glands. The results of this study are encouraging, and further work is warranted with a higher sample size. Conclusion We demonstrated that critical histopathological features of the prostate gland can be identified with high resolution ex vivo MRI examination and offer promise that MR microscopy of PCa will ultimately be possible in vivo. This article is protected by copyright. All rights reserved.
  • Role of Prostate Artery Embolization (PAE) in the Management of Refractory
           Hematuria of Prostatic Origin
    • Abstract: Prostatic hematuria is among the most common genitourinary complaints of emergency room visits, distressful and troublesome to men and a challenging clinical problem to the treating physician. The most common etiologies of prostatic hematuria include benign prostatic hyperplasia and prostate cancer. Prostatic hematuria usually resolves with conservative and medical methods; failure of these interventions results in refractory hematuria of prostatic origin (RHPO), a potentially life‐threatening scenario. Several different treatments have been described, with varying degrees of success. Patients with RHPO are often elderly and unfit for radical surgery. Prostate artery embolization (PAE) has evolved as a safe and effective technique in the management of RHPO. Use of a superselective approach optimizes clinical success while minimizing complications. This minimally invasive approach improves patients with hemodynamic instability, serves as a bridge to elective surgery, and is a highly effective treatment for RHPO. It may obviate the need for more invasive and morbid surgical therapies. The aim of this review is to describe the current management of RHPO, the technique of PAE and review its efficacy and morbidity. This article is protected by copyright. All rights reserved.
  • Getting Personal with Prostate Cancer: DNA‐Repair Defects and
           Olaparib in Metastatic Prostate Cancer
    • Abstract: Despite the progress that has been made in the treatment of advanced prostate cancer, many patients with metastatic prostate cancer still progress to hormone resistance. Development of new agents has greatly expanded the treatment options for metastatic castrate resistant prostate cancer (mCRPC), however their impact on survival outcomes have been limited. There remains an acute need for improvements in the prognostic assessment and targeted treatment of mCRPC. This article is protected by copyright. All rights reserved.
  • Pre‐biopsy 3T MRI and targeted biopsy of the index prostate cancer
           – correlation with robot assisted radical prostatectomy
    • Abstract: Objective To study whether pre‐biopsy 3T prostate MRI with targeted biopsy allows for accurate anatomical and oncological characterisation of the index prostate tumour and if this translates into improved positive surgical margin (PSM) rates after radical prostatectomy. Patients and methods Retrospective analysis of all men (n=201) who underwent robot‐assisted radical prostatectomy (RARP) between July 2012‐Juy 2014 Patients were divided into a study group (n=63) who had undergone pre‐biopsy 3T MRI, followed by visual targeted and systematic prostate biopsy; and a control group (n=138) who had undergone systematic biopsy alone. The two groups were well matched regarding patient and cancer characteristics. The primary study objective was to assess the accuracy of pre‐biopsy MRI for localising the index tumour Secondary study objectives were to assess the accuracy of MRI for the maximal tumour diameter(MTD) of the index tumour focus; and accuracy of the targeted biopsy for the Gleason score and primary Gleason grade of the index tumour focus and whether PSMs were improved after RARP The reference standard was whole gland pathology of the resected prostate gland. Continuous variables and proportions were compared using the t‐test and Mann Whitney test; or contingency tables respectively. Pearson correlation coefficient and Bland Altman plots were used to compare measurement of MTD. Results MRI accurately located the index tumour focus in 73%. Accuracies stratified according to PI‐RADS category 5, 4 and 3 were 94%, 75% and 60% respectively. Accuracies stratified according to MTD of ≤ 0.7cm, ≤1cm and > 1cm were 50%, 57% and 79% respectively. There was a positive linear correlation between MRI and histological MTD [r =0.42 (95% CI: 0.16‐0.63),; p=0.002]; but MRI generally underestimated the MTD – mean (95%CI) MRI measured MTD was 1.51cm (1.29‐1.72cm) vs. pathological MTD of 2.15cm (1.86‐2.43cm) Targeted biopsy identified 37% more cancer per core than non‐targeted biopsy. Mean (95% CI) maximal core length was 8.9mm (7.8‐10mm) vs. 6.5mm (5.8‐7.2mm); study and control groups respectively (p=0.0002;non‐paired t test) Gleason scoring was significantly more predictive after targeted biopsies, with unchanged scores in 40/63 (63%) vs. 62/138 (45%) in study and control groups respectively (p = 0.001; Fisher's test). The odds of Gleason up grading were 2.5 (p=0.028) greater in the control group. The primary Gleason grade was not significantly different in the two groups [45/63 (71%) vs. 91/138 (66%); study vs. control group respectively (p =0.51, Fisher's test)]. Overall PSMs were non‐significantly lower in the study group (15.8% vs. 18.8%; p = 0.84, Fisher's test); and the MRI location of the index tumour focus correlated with the site of PSM in 70% of cases in the study group Conclusion Pre‐biopsy MRI can accurately identify the index prostate tumour, especially in those with higher PI‐RADS grades and tumour diameter. Targeted biopsy of this focus retrieves significantly more cancerous tissue per core, and is more accurate regarding Gleason scores, but not primary Gleason grade. MRI underestimates MTD and PSMs were not significantly improved in our study This article is protected by copyright. All rights reserved.
  • Trends in urological stone disease: a 5‐year update of Hospital
           Episode statistics
    • Abstract: Objective To provide a 5‐year follow‐on update on the changes in prevalence and treatment of upper urinary tract stone disease in the UK. Methods Data from the Hospital Episode Statistics (HES) website (w w w hesonline . nhs . uk ) were extracted, summarized, analysed and presented. Results The total number of upper urinary tract stone hospital episodes increased slightly from 83,050 in 2009‐10 to 86,742 in 2014‐15 (4.4% increase). The use of shock wave lithotripsy (SWL) for treating all upper tract stones remained stable over the 5‐year study period following a significant increase in previous years. There was a 49.6% increase in the number of ureteroscopic stone treatments from 12,062 in 2009‐10 to 18,055 in 2014‐15. Increase in ureterorenoscopy (flexible ureteroscopy) demonstrated the most rapid increase from 3267 to 6631 cases in the 5‐year study period (103% increase). The gap between the total number of ureteroscopies and SWL treatments continues to narrow. Open stone surgery continued to decline with only 30 reported cases in 2014‐15. Due to the continued rapid increase in the number of ureteroscopies performed, treatment for stone disease has continued to increase significantly in comparison to other urological activity. Conclusion This study provides an update on the changing landscape of the management of urinary tract stones in the UK. It demonstrates a sustained high prevalence of stone disease in the UK commensurate with levels in other developed countries. This study reveals a trend in the last 5 years to surgically intervene on a higher proportion of patients with stones. As in other countries, there is a significant increase in the use of ureteroscopy (particularly intrarenal flexible ureteroscopy) in the UK. These data have important implications for work‐force planning, training, service delivery and research in the field of urolithiasis. This article is protected by copyright. All rights reserved.
  • Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER
    • Abstract: Objectives To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved radical cystectomy (RC) quality of care (Quality Improvement in Cystectomy Care with Enhanced Recovery‐QUICCER) defined by a decrease in length of stay (LOS) without an increase in complications or readmissions compared to those not managed with CERP. Subjects and Methods QUICCER is a non‐randomized quasi‐experimental study. Data were collected from June 2011 to April 2015. The CERP was implemented in July 2013. The primary endpoint was LOS. Secondary endpoints were quality scores, complications and readmissions. Multivariable regression was performed. Propensity score matching was done to further simulate randomized clinical trial conditions. A CERP quality composite score was created and evaluated for adherence to CERP elements. Results There were 79 CERP and 121 non‐CERP patients included. After matching, there were 75 non‐CERP patients. The LOS was significantly different. The CERP and non‐CERP groups had a median LOS of 5 days and 8 days, respectively, p < 0.001. Multivariable linear regression revealed any complication was the most significant predictor of total hospital days at 90 days after RC. The higher the quality composite score the shorter the length of stay, p < 0.001. There was no association of the CERP and increased complications or readmissions. Conclusions Audited quality measures in the CERP are associated with a reduction of LOS without increasing readmissions or complications. The CERP is important in the future improvement of RC perioperative care and provides an opportunity to improve the quality of care provided. This article is protected by copyright. All rights reserved.
  • Urethral fixation technique improves early urinary continence recovery in
           patients who underwent Retropubic Radical Prostatectomy
    • Abstract: Objectives to describe step by step an original urethra‐vesical anastomosis technique (Urethral fixation) in patients who underwent retropubic radical prostatectomy (RRP) and compare the observed early urinary continence recovery rates with those reported in a control group receiving a standard anastomosis technique. Moreover, we identified the predictors of early urinary continence recovery. Patients and methods We compared 70 patients who underwent RRP with urethral fixation technique with a contemporary control group of 51 patients who received RRP with a standard urethra‐vesical anastomosis. In the study group, the urethra‐vesical anastomosis was performed using 8 single stitches. Specifically, to avoid retraction and/or deviations we fixed the urethral stump laterally to the medial portion of levator ani muscle. Moreover, to maintain the normal position in the context of pelvic floor we fixed the urethra sphincter deeper to the medial dorsal rafe using a 3‐0 PDS stitch at 6 o'clock before completing the incision of the urethral wall. Urinary continence recovery was evaluated 1 week, 1, 2 and 3 months after catheter removal. Patients self‐reporting no urine leak were considered continent. Univariable and multivariable analyses were used to identify predictors of urinary incontinence at different follow‐ups. Results The two evaluated groups resulted comparable for all the pre‐operative variables. One week after catheter removal, 32 (45.7%) patients in the study group and 10 (19.6%) in the control group were continents (p=0.01), respectively. Similarly, 1 month after catheter removal, 46 (65.7%) patients in the urethral fixation group and 16 (31.4%) declared to be continent (p=0.001), respectively. Two months after catheter removal, 59 (84.3%) patients in the study group and 21 (41.2%) in the control group were continents (p
  • High PCA3 scores are associated to elevated Prostate Imaging Reporting and
           Data System (PI‐RADS) grade and biopsy Gleason Score, at MRI/US
           fusion software‐based targeted prostate biopsy after a previous
           negative standard biopsy
    • Abstract: Objective to determine the association among PCA3 score, Prostate Imaging Reporting and Data System (PI‐RADS) and Gleason Score (GS), in a cohort of patients with elevated PSA, undergoing MRI/US fusion software‐based targeted prostate biopsy (TBx) after a previous negative randomized “standard” biopsy (SBx) Patients and Methods 282 patients, undergone to TBx after previous negative SBx and PCA3 urine assay, were enrolled. The associations PCA3 score/PI‐RADS and PCA3 score/GS were investigated by K‐means clustering, ROC analysis and binary logistic regression model Results PCA3 score difference for negative versus positive TBx cohorts was highly statistically significant. One unit of increase in PCA3 score was associated to a 2.4% increased risk to have a positive TBx result. PCA3 score>80 and PI‐RADS≥4 were independent predictors for a positive TBx. The association between PCA3 score and PI‐RADS was statistically significant (PCA3 score median value for PI‐RADS groups 3‐4‐5 was 58‐104‐146, respectively; p=0.006). A similar pattern was detected for the relationship between PCA3 score and GS; an increasing PCA3 score was associated to a worse GS (median PCA3 score equal to 62‐105‐132‐153‐203‐322 for GS 3+4, 4+3, 4+4, 4+5, 5+4, 5+5, respectively; p
  • Evolution and oncological outcomes of a contemporary radical prostatectomy
           practice in a UK regional tertiary referral centre
    • Abstract: Objective To investigate the clinical and pathological trends over a ten‐year period for robotic‐assisted laparoscopic prostatectomy (RALP) in a UK regional tertiary referral centre. Patients and Methods 1500 consecutive patients underwent RALP between October 2005 and January 2015. Prospective data was collected on clinic‐pathological details at presentation as well as surgical outcomes and compared over time. Results The median(range) age of patients throughout the period was 62(35‐78) years. The proportion of pre‐operative high‐grade cases (Gleason sum 8‐10) rose from 4.6% in 2005‐2008 to 18.2% in 2013‐2015 (p
  • Recent advances in immuno‐oncology and the application to urological
    • Abstract: Recent advances in immuno‐oncology have the potential to transform the practice of medical oncology. Antibodies directed against negative regulators of T cell function (checkpoint inhibitors), engineered cell therapies, and innate immune stimulators such as oncolytic viruses are effective in a wide range of cancers. Immune‐based therapies have had a clinically meaningful impact on the treatment of advanced melanoma and the lessons regarding use of single agents and combinations in melanoma may be applicable to the treatment of urological cancers Checkpoint inhibitors, cytokine therapy and therapeutic vaccines are already showing promise in urothelial bladder cancer, renal cell carcinoma and prostate cancer. Critical areas of future immuno‐oncology research include the prospective identification of patients who will respond to current immune‐based cancer therapies, and the identification of new therapeutic agents that promote immune priming in tumors, and increase the rate of durable clinical responses. This article is protected by copyright. All rights reserved.
  • Robot‐assisted Fallopian Tube Transection‐anastomosis using
           the New REVO‐I Robotic Surgical System: Feasibility in a Chronic
           Porcine study
    • Abstract: Objectives Fallopian tube anastomosis is used for basic robotic training (Intuitive Surgical) because it emphasizes the unique advantages of a robotic surgical system (fine motor movements required for intracorporeal suturing, 3D vision, motion scaling, and tremor control). Furthermore, fallopian tube anastomosis resembles robotic radical prostatectomy in regards to port placement, pelvic area approach, and urethrovesical anastomosis. The aim of our study was to evaluate the feasibility and safety of the new REVO‐I robotic platform by performing fallopian tube transection‐anastomosis in live porcine models. Material and Methods A prospective chronic animal study was carried out in four Crossbred female pigs. The primary outcome was assessment of the pigs’ 2‐week survival. The secondary outcomes were measurements of intraoperative parameters and the complications or difficulties when using the REVO‐I. Results Fallopian tube anastomosis was successfully performed in 4 porcine models. The mean operative time was 66 min (range: 46‐104 min), the mean docking time was 22.25 min (range: 14–53 min), and the mean console time was 18 min (range: 13–20 min). The REVO‐I robotic system functioned appropriately, with no technical problems or difficulties noted during the procedures. Both the surgeon and the bed‐side assistants reported ease of use and better performance with subsequent procedures. All pigs were alive 2 weeks after surgery, with no perioperative complications related to the use of the robot. Conclusions The current pre‐clinical chronic animal study revealed that the REVO‐I robotic surgical system is a feasible and safe robotic instrument that can be used by surgeons to perform skillful robotic procedures in porcine models. Our next objective is to demonstrate its safety in humans. This article is protected by copyright. All rights reserved.
  • Testosterone Undecanoate improves Sexual Function in Men with Type 2
           diabetes and Severe Hypogonadism: Results from a 30 week randomized
           placebo controlled study
    • Abstract: Objective To evaluate the Sexual Function response to 30 weeks treatment with Long Acting Testosterone Undecanoate (TU) or Placebo (P) 199 men with type 2 diabetes and either severe or mild hypogonadism. Patients and Methods Men with hypogonadism (HG) were identified from 7 primary care T2DM registers. A 30 week randomised placebo controlled study of TU was carried out in 199 of these men (P: 107, TU: 92). The patient reported outcome measure was the IIEF ‐15. Men completing the study (n=189) were stratified firstly, by baseline total testosterone (TT) / free testosterone (FT) into Mild HG (TT 8.1–12nmol/l or FT 0.18‐0.25nmol/l) and Severe HG groups (TT ≤8nmol/l and FT ≤0.18nmol/l) and secondly by intervention (P and TU) leading to 4 groups; Mild HG/P, Mild HG/TU, Severe HG/P and Severe HG/TU. Statistical Analysis Changes in sexual function score (a secondary outcome of the study) at each visit within group (cf. baseline) and between groups (TU vs P) at each assessment (6, 18 and 30 weeks) were compared using Wilcoxon signed‐rank and Wilcoxon rank sum tests respectively. Results Significant improvement in erectile function was evident only in the Severe HG group following TU after 30 weeks, this finding also present when TU was compared to P. Intercourse satisfaction and sexual desire scores were also improved in the Severe HG group following TU at 6, 18 and 30 weeks, this increase in scores also evident when compared to P. TU did not appear to significantly alter orgasmic function in any of the patient groups. Conclusions Our study suggests that benefit in sexual symptoms following TU was evident principally in patients with HG with TT ≤8nmol/l and FT ≤0.18nmol/l. We also suggest 30 weeks of treatment is necessary before evaluating improvement in erectile function. This article is protected by copyright. All rights reserved.
  • Mirabegron causes relaxation of human and rat corpus cavernosum: could it
           be a potential therapy for erectile dysfunction'
    • Abstract: Objective To examine the effects of mirabegron, a selective β3‐AR agonist that has recently been approved for the treatment of overactive bladder, in rat and human erectile tissues with a focus on elucidating the mechanism of such an action. Stimulation of β3‐adregenic receptors (ARs) localized in cavernosal smooth muscle cells may play a physiological role in mediating penile erection, and offer a beneficial pharmacologic action for the patient who has overactive bladder and erectile dysfunction (ED). Materials and Methods Corpus cavernosal (CC) specimens were obtained from patients with ED and Peyronie's disease undergoing penile prosthesis implantation. Erectile responses were also evaluated in vivo following intracavernosal injection (ICI) of mirabegron in anesthetized rats. Mirabegron‐elicited relaxation responses (10‐8‐10‐3 M) on phenylephrine (Phe)‐induced contraction were observed in human and rat CC strips in isolated organ bath studies. The effects of inhibitors namely L‐NAME [N(G)‐nitro‐L‐arginine methyl ester (a competitive inhibitor of NO synthase), 100μM), ODQ [1H‐(1,2,4) oxadiazolo(4,3‐α) quinoxalin‐1‐one (a nitric oxide‐sensitive guanylyl cyclase (GC) inhibitor, 30μM), methylene blue (a NOS and GC inhibitör, 20μM), SR59230A (β3‐AR blocker, 1 μM), and fasudil (Rho‐kinase (ROCK) inhibitor, 0.1 μM)] on mirabegron‐induced relaxation responses were evaluated. Responses to mirabegron were compared with responses to isoprenaline and nebivolol. Immunohistochemistry was used to localize β3‐AR and ROCK in CC smooth muscle cells. In vivo rat data were expressed as intracavernosal pressure (ICP)/mean arterial pressure and total ICP. Results Mirabegron resulted in a relaxation of Phe‐evoked CC contractions in a concentration‐dependent manner and SR59230A antagonized mirabegron‐induced relaxations in human and rat CC. Other inhibitors, L‐NAME, ODQ, and methylene blue, did not affect the mirabegron‐induced relaxation responses. Mirabegron relaxation responses at concentrations (between 0.1 and 10μM) were enhanced by fasudil (ROCK inhibitor) in rat but not in human CC strips. KCl‐induced contractions in human and rat CC were partially inhibited by mirabegron. In vivo ICI of mirabegron (doses of 0.1 – 1 mg/kg) had a minor effect on ICP when compared to vehicle administration. Immunohistochemistry data showed β3‐ARs localization into the smooth muscle cells of human and rat CC. Conclusions Mirabegron markedly relaxed isolated CC strips by activating β3‐ARs independently of the NO‐cGMP pathway. There is also evidence of the existence of a close functional link between β3‐ARs and the RhoA/ROCKpathway. These results may support further clinical studies using combinations of mirabegron with ROCK and phosphodiesterase‐5 inhibitors (PDE5i) for the treatment of ED, especially in patients who do not respond to PDE5i therapy. This article is protected by copyright. All rights reserved.
  • Robotic assisted technique for boari flap ureteral reimplantation
           (RA‐BFUR): replicating the techniques of open surgery in robotics
    • Abstract: The video describes our approach of a Robotic assisted Boari Flap Ureteral Reimplantation (RA‐BFUR). The technique is based on the open surgical technique of Übelhör. The experience includes 11 cases with excellent results after a mean follow‐up period of more than 12 months. RA‐BFUR could be considered as a safe and effective method of ureteral reimplantation of long distal ureteral strictures. This article is protected by copyright. All rights reserved.
  • Outcomes of high complex renal tumor (PADUA ≥ 10) following
           robot‐assisted partial nephrectomy with a median 46 months
           follow‐up: A tertiary center experience
    • Abstract: Objectives To compare peri‐operative trifecta achievement and long‐term oncological and functional outcomes between low (6‐7), intermediate (8‐9) and high (≥10) PADUA complex renal tumors and to determine predictors for trifecta achievement. Material and Methods A retrospective analysis of data from 295 patients, who underwent RPN between 2006 to 2015 at high‐volume tertiary center was performed. Trifecta achievement was the main primary outcome measurement. The perioperative parameters and long‐term oncological and functional outcomes were the secondary outcome measurements. Groups were compared using Kruskal‐Wallis H test or chi‐square. Univariable and multivariable binary logistic regression analyses were performed to determine the most important determinant variables associated with trifecta accomplishment. The Kaplan‐Meier method was used to estimate for overall survival (OS), cancer‐specific survival (CSS) and cancer‐free survival (CFS). Results Out of 295 patients, 121 (41%) had PADUA score ≥10. Patients in high complex PADUA group had a larger tumor size, higher clinical stage ≥T1b, an increased risk of malignancy, longer warm ischemia time (WIT) and increased estimated blood loss (EBL) compared to intermediate and low complex groups (p=
  • Attitudes and Knowledge of Urethral Catheters: A Targeted Educational
    • Abstract: Objectives To assess the training of medical students and their confidence in urethral catheter placement, given growing evidence of unnecessary urology consults and iatrogenic injury. Methods A third‐year medical school class was queried regarding their attitudes and knowledge of catheter placement prior to and after the Clinical Biennium. The Clinical Biennium introduces hands on skills prior to clinical clerkships. Urethral catheterization is one of the skill stations that students rotate through, and urology residents provide a didactic session and supervised simulation. Confidence was self‐rated regarding catheter technique, knowledge, troubleshooting, and comfort with placement in same and opposite gender. Factual questions were posed regarding proper insertion and malfunctioning catheters. Results Ninety‐two students participated in the initial survey, 41% female and 59% male. 87% of students had never placed a catheter. Students desired high confidence in catheter skills (4.4/5). There were no significant differences in responses for those with desire to pursue urology vs. other specialties, or procedural fields compared to non‐procedural fields. Prior independent learning was reported by 38% of students and was a predictor for increased confidence across all domains (p
  • Correlation between stage shift and differences in mortality in the
           European Randomized study of Screening for Prostate Cancer (ERSPC)
    • Abstract: A 21% prostate cancer (PCa) mortality reduction was observed in the European Randomized Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow‐up. A direct correlation between stage shift and changes in PCa‐mortality would support earlier detection through screening as the main reason for this reduction. In this study we empirically estimate how changes in the risk of being diagnosed with (advanced) PCa are related to the changes in PCa death in the ERSPC using a meta‐regression approach. In total 81% and 89% of the changes in PCa mortality could be explained by changes in PCa incidence. Although this analysis cannot show direct causal relations, results support the hypothesis that PSA screening reduced PCa mortality by detecting cancer at an earlier stage while still curable. These findings do however not open the way to unrestricted PSA based screening for PCa. A balance between harm and benefit needs to be found. This article is protected by copyright. All rights reserved.
  • Detecting Positive Surgical Margins: Utilization of Light Reflectance
           Spectroscopy on ex vivo Prostate Specimens
    • Abstract: Objective To assess the efficacy of Light reflectance spectroscopy (LRS) to detect positive surgical margins (PSM) on ex vivo radical prostatectomy specimens. Materials and Methods A prospective evaluation of ex vivo prostate specimens using LRS was performed at a single institution from June 2013 to September 2014. LRS measurements were performed on selected sites on prostate capsule, marked with ink, and correlated with pathologic analysis. Significant features on LRS curves differentiating malignant tissue from benign tissue were determined using a forward sequential selection algorithm. A logistic regression model was built and randomized cross‐validation was performed. The sensitivity, specificity, accuracy, NPV, PPV, and area under the receiver operating characteristic curve (AUC) for LRS predicting PSM were calculated. Results Fifty prostate specimens were evaluated using LRS. LRS sensitivity for Gleason ≥7 PSM was 91.3%, specificity 92.8%, accuracy 92.5%, PPV 73.2%, NPV 99.4%, and AUC = 0.960. LRS sensitivity for Gleason ≥6 PSM was 65.5%, specificity 88.1%, accuracy 83.3%, PPV 66.2%, NPV 90.7%, and AUC = 0.858. Conclusions LRS can reliably detect positive surgical margins for Gleason 7 or above prostate cancer in ex vivo radical prostate specimens This article is protected by copyright. All rights reserved.
  • Toxicity and efficacy of salvage 11C‐Choline PET/CT‐guided
    • Abstract: Objective To report the 3‐year toxicity and outcome results of 11C‐Choline positron emission tomography/computed tomography (11C‐Ch‐PET/CT)‐guided radiotherapy, delivered with helical tomotherapy (Tomotherapy® Hi‐Art II® Treatment System, Accuray Incorporated, USA) (HTT) of lymph‐nodal (LN) relapses in prostate cancer patients. Patients and methods From 01/2005 to 03/2013, 81 patients with biochemical recurrence – after surgery±adjuvant/salvage radiotherapy (RT) or radical RT and with evidence of LN 11C‐Ch‐PET/CT pathological uptake underwent HTT (median PSA: 2.59(0.61‐187) ng/ml). 72/81 patients were treated on pelvic and/or lumbar‐aortic LN chain with HTT at 51.8 Gy/28 fr and with simultaneous integrated boost (SIB) to a median dose of 65.5 Gy on the pathological uptake sites detected by 11C‐Ch‐PET/CT. Nine patients were treated without SIB(50‐65.5 Gy, 25‐30 fr). Results With a median follow‐up of 36 (9‐116) months, 91.4% of the patients presented a PSA reduction 3 months after HTT. The 3 year overall, local‐relapse‐free and clinical‐relapse‐free survival were 80.0%, 89.8% and 61.8%, respectively. The 3‐year actuarial incidences of ≥G2 rectal and ≥G2 GU toxicity were 6.6% (± 2.9%) and 26.3% (±5.5%) respectively. A PSA nadir ≥0.26 ng/ml (HR:3.6; 95%CI 1.7‐7.7, p=0.001), extra‐pelvic 11C‐Ch‐PET/CT positive LN location (HR:2.4; 95%CI 0.9‐6.4, p=0.07), RT previous to HTT (HR:2.7; 95% CI 1.07‐6.9, p=0.04) and number of positive LN (HR:1.13; 95%CI 1.04‐1.22, p=0.003) were the main predictors of clinical relapse after HTT . Conclusions 11C‐Ch‐PET/CT‐guided HTT is safe and effective in the treatment of LN relapses of previously treated prostate cancer patients. This article is protected by copyright. All rights reserved.
  • Performance of Robotic Simulated Skills Tasks is Positively Associated
           with Clinical Robotic Surgical Performance
    • Abstract: Objective To compare user performance of four Fundamental Inanimate Robotic Skills Tasks (FIRST) as well as eight da Vinci Skills Simulator (dVSS) virtual reality tasks to intraoperative performance (concurrent validity) during robotic prostatectomy (RP). Our group has previously demonstrated face, content, and construct validity of these simulated robotic skills tasks. As there is no data in the robotic environment showing a significant relationship between simulation and clinical performance, we aim to show that a positive correlation exists between simulation and intraoperative performance. Materials and Methods Twenty‐one urologic surgeons of varying robotic experience were enrolled. Demographics were captured using a standardized questionnaire. User performance was assessed concurrently in simulated (FIRST exercises and dVSS tasks) and clinical environments (endopelvic dissection during RP). Intraoperative robotic clinical performance was scored using the previously validated 6‐metric Global Evaluative Assessment of Robotic Skills (GEARS) tool. Relationship between simulator and clinical performance was evaluated using Spearman's rank correlation. Results Performance was assessed in 17 trainees and 4 expert robotic surgeons with a median (range) number of previous robotic cases (as primary surgeon) of 0 (0‐55) and 117 (58‐600), respectively (p=0.001). Collectively, the overall FIRST (ρ=0.833, p
  • Early MAG‐3 diuretic renography results after pyeloplasty
    • Abstract: Objectives To describe the drainage and functional outcome following paediatric pyeloplasty, one week after stent removal (seven to nine weeks after pyeloplasty) using diuretic renography. Patients and Methods Between 2009 and 2014, we assessed the functional and drainage outcomes on mercaptoacetyltriglycine (MAG‐3) diuretic renograms from 66 children (69 kidneys) who underwent modified dismembered Anderson‐Hynes pyeloplasty for UPJ obstruction. Stents were left in place for 6 to 8 weeks and postoperative renal units were evaluated with MAG‐3 renogram one week after stent removal. Surgical success was defined by improvement of drainage (T/2 less than 20 min), stable or improved function on the postoperative MAG‐3 renogram and by decreased pyelocaliceal dilatation on US at one year. Results Of the 69 kidneys with preoperative median T/2 of 33.4 min (range 7.6‐200 min), 87% (60/69) had improved drainage curves with a median T/2 of 6.9 min (range 1.6‐19 min). Thirteen percent (9/69) had persistent impaired drainage with a median T/2 of 36 min (range 24‐108 min). One girl was found with a persistent obstructive pattern (T/2= 30 min) associated with a decreased SRF (from 42 to 33%) and a persistent hydronephrosis (at 28mm). Redo‐pyeloplasty was performed 2 months after the initial procedure (and 18 days after stent removal) and renal function recovered to 47%. All other 8 patients were free of symptoms; hydronephrosis improved at 1 year (anteroposterior diameter decreased from 28 to 18.5 mm, p=1.94) and SRF remained stable (44.5% versus 48.5% after repair, p=ns). Of the 29% (20/69) that had preoperative impaired SRF, postoperative renal function improved in 75% (from 27.5 to 43%, p=0.0002), remained unchanged in 2% and one (0.2%) deteriorated. Median postoperative follow‐up was 18 months (range 12‐90 months). Discussion There is no agreement regarding the gold standard investigation to use following pyeloplasty for ureteroplevic junction (UPJ) obstruction. Improvement in hydronephrosis on ultrasound (US) is slow and often takes more than 12 months. Based on animal studies, it is possible that missed recurrent obstruction will cause irreversible loss of renal function after 6 weeks. Therefore early postoperative assessment is desirable but there have been few reports on urinary drainage changes with early diuretic renography after pyeloplasty. Conclusion Most of renal units have improved drainage on diuretic renography 7 weeks after pyeloplasty and 1 week after stent removal. An early diuretic renogram is a reliable method of documenting surgical success after pyeloplasty. This article is protected by copyright. All rights reserved.
  • If the robot is there, why not use it' Why we should use the robot for
           laparoscopic nephrectomy
    • Abstract: Robot‐assisted laparoscopic nephrectomy (RALN) was first described over 10 years ago [1]. However, with the wide availability of established and experienced laparoscopic surgeons, investigation into the role and potential benefits of RALN has been limited. Many consider RALN to bare no additional benefits over laparoscopic radical nephrectomy (LRN) but see it as merely expensive, and regard it as ‘technical overtreatment’. On the other hand, robotic surgery improves laparoscopic dexterity with a better range of movement, three‐dimensional vision, tremor filtration, and motion scaling leading to better eye‐hand coordination. It is a tool for complex laparoscopic surgery and is indeed a very good one, but is there a role for RALN' This article is protected by copyright. All rights reserved.
  • Symptomatic and quality of life outcomes following treatment for
           clinically localized prostate cancer: a systematic review
    • Abstract: Objectives To conduct a systematic review of the risks of short‐term outcomes following major treatments for clinically localized prostate cancer. Materials and methods MEDLINE, EMBASE and the Cochrane Library from 2004 to January 2013. Study arms that included at least 100 men with localized prostate cancer in receipt of surgery, radiotherapy or active surveillance and reported symptomatic and quality of life (QoL) data from 6 months to five years after treatment were eligible. Data were extracted by one reviewer and checked by another. Results 64 studies (80 treatment cohorts) were included. Most were single treatment cohorts from the US or Europe. Prostatectomy was the most common treatment (39 cohorts), followed by radiotherapy (external beam and brachytherapy; 31 cohorts), with only one active surveillance cohort. Most frequently measured symptoms were urinary, followed by sexual and bowel; QoL was assessed in only 17 cohorts. Most studies used validated measures, although poor data reporting and differences between studies meant that it was not possible to pool data. Conclusion Data on the precise impact of short‐term symptomatic and QoL outcomes following treatment for localized prostate cancer is of insufficient quality for clear guidance to men about the risks to these aspects of their lives. It is important that future studies focus on collecting core outcomes through validated measures and comply with reporting guidelines so that clear and accurate information can be derived for men considering screening or treatment for prostate cancer. This article is protected by copyright. All rights reserved.
  • Results of a randomized, double‐blind, active‐controlled
           clinical trial with propiverine ER 30 mg in patients with overactive
    • Abstract: Objective To compare the efficacy and safety of the 30 mg extended release (ER) formulation of propiverine hydrochloride with the 4 mg extended release formulation of tolterodine tartrate in patients with overactive bladder in a non‐inferiority trial. Patients and methods Eligible patients aged between 18 and 75 years with symptoms of OAB were enrolled in this multicentre, randomized, double‐blind, parallel‐group, active‐controlled study. After a 2‐week screening period patients were randomized at a 1:1 ratio to receive either propiverine ER 30 mg or tolterodine ER 4 mg daily during the 8‐weeks treatment period. The efficacy was assessed using a 3‐days voiding diary and patient's self‐reported assessment of treatment effect. Safety assessment included recording of adverse events, laboratory test results, measurement of post void residual urine, and electrocardiograms. Results A total of 324 patients (244 female, 80 male) were allocated into the study. Both active treatments improved the variables of the voiding diary and patient's self‐reported assessment. The change from baseline in the number of voidings per 24 h was significantly greater in the propiverine ER 30 mg group compared to the tolterodine ER 4 mg group after 8 weeks of treatment (FAS; ‐4.6±4.1 vs. ‐3.8±5.1, p=0.005). Significant improvements were also observed for the change of urgency incontinence episodes after 2 weeks (p=0.026) and 8 weeks (p=0.028) of treatment when comparing propiverine ER 30 mg with tolterodine ER 4 mg. Both treatments were well tolerated with a comparable frequency of adverse drug reactions between propiverine ER 30 mg and tolterodine ER 4 mg (FAS; 40.7% vs. 39.5%, p=0.8). More patients treated with tolterodine ER 4 mg discontinued the treatment due to adverse drug reactions compared to propiverine ER 30 mg (7.4% vs. 3.1%). Conclusions Propiverine ER 30 mg was confirmed to be an effective and well‐tolerated treatment option for patients suffering from overactive bladder symptoms. This first head‐to‐head study demonstrated non‐inferiority of propiverine ER 30 mg compared to tolterodine ER 4 mg. This article is protected by copyright. All rights reserved.
  • Patient‐physician‐communication and health related quality of
           life of localized prostate cancer patients undergoing radical
           prostatectomy – a longitudinal multilevel analysis
    • Abstract: Objectives To examine whether patient‐physician‐communication is associated with health related quality of life (HRQoL) in a sample of localized prostate cancer patients after radical prostatectomy. Patients and methods HAROW is a prospective, observational study designed to collect data of the different treatment options (Hormonal therapy, Active Surveillance, Radiation, Operation, Watchful Waiting) for newly diagnosed patients with localized prostate cancer under real life conditions. At 6‐months intervals, clinical data (D'Amico risk categories, Charlson comorbidity index) aspects of patient‐provider‐communication (standardized psychosocial care‐instrument for patients’ assessment of communication; Cologne Patient Questionnaire), and HRQoL (EORTC QLQ‐C30) were assessed. Data were analyzed by longitudinal multilevel analysis. Results Completed questionnaires for N=1.772 patients undergoing a prostatectomy were analyzed for a 3 year follow‐up period. Patients rate the patient‐provider communication generally high with slight variations over the course of treatment (3.2‐3.8). The HRQoL of the patients shows substantial variation over time and between the reported subscales (Global Qol 71,1‐77,2; physical functioning 89,1‐92,1; role functioning 81,0‐88,1; emotional functioning 74,4‐84,0; cognitive functioning 84,3‐87,7; social functioning 77,7‐84,0). The longitudinal multilevel models showed significant associations between the patient‐provider communication in terms of devotion, support and co‐therapy and functional aspects of HRQoL. Conclusion Patient‐provider communication is a valuable resource to support prostate cancer patients’ coping with the disease and to improve their HRQoL. Future interventions should be designed especially for urologists to enhance their awareness for the importance of communication and the relationship to their prostate cancer patients for treatment outcomes. This article is protected by copyright. All rights reserved.
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