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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  [1609 journals]
  • Transgenic Animal Model for Studying the Mechanism of Obesity‐Associated
           Stress Urinary Incontinence
    • Abstract: Purpose To study and compare the function and structure of the urethral sphincter in female Zucker lean and Zucker fatty (ZF) rats and to assess viability of ZF fats as a model for female obesity‐associated stress urinary incontinence (OA‐SUI). Materials and Methods Twelve16‐week‐old female Zucker Lean (ZUC‐Leprfa 186) (ZL) rats and twelve16‐week‐old female Zucker Fatty (ZUC‐Leprfa 185) (ZF) rats were grouped into two groups: ZL arm and ZF arm. Intraperitoneal insulin tolerance testing was carried out before functional study. Metabolic cages, conscious cystometry, and leak point pressure (LPP) were conducted. Urethral tissues were harvested for immunofluorescence staining to check intramyocellular lipid (IMCL) and sphincter muscle (smooth muscle and striated muscle) composition. Results The ZF rats demonstrated insulin resistance, increased voiding frequency, and decreased LPP compared to ZL rats (p
      PubDate: 2016-09-21T04:24:31.647568-05:
      DOI: 10.1111/bju.13661
  • Phenotypic diversity of circulating tumour cells in patients with
           metastatic castration‐resistant prostate cancer
    • Authors: Andrew S. McDaniel; Roberta Ferraldeschi, Rachel Krupa, Mark Landers, Ryon Graf, Jessica Louw, Adam Jendrisak, Natalee Bales, Dena Marrinucci, Zafeiris Zafeiriou, Penelope Flohr, Spyridon Sideris, Mateus Crespo, Ines Figueiredo, Joaquin Mateo, Johann S. de Bono, Ryan Dittamore, Scott A. Tomlins, Gerhardt Attard
      Abstract: Objectives To utilize a non‐biased assay of circulating tumour cells (CTCs) in prostate cancer (PCa) patients in order to identify non‐traditional CTC phenotypes potentially excluded by conventional detection methods reliant upon antigen and/or sized based enrichment. Patients and Methods 41 metastatic castration resistant prostate cancer (mCRPC) patients and 20 healthy volunteers were analysed on the Epic CTC Platform, via high throughput imaging of DAPI expression and CD45/cytokeratin (CK) immunofluorescence (IF) in all circulating nucleated cells plated on glass slides. IF for androgen receptor [AR] expression, and FISH for PTEN and ERG confirmed PCa origin of CTCs. Results Traditional (t) CTCs (CD45‐/CK+/morphologically distinct) were identified in 100% mCRPC patients. Using the above markers, we identified non‐traditional CTCs in mCRPC patients, including CK‐ and apoptotic CTCs. Small CTCs (≤WBC size) were identified in 98% of mCRPC patients. Total, traditional and non‐traditional CTCs were significantly increased in deceased vs. living patients at 18 months; however only non‐traditional CTCs associated with overall survival. Traditional and total CTC counts by the Epic platform in the mCRPC cohort were also significantly correlated with CTC counts by the CellSearch system. Conclusions Heterogeneous non‐traditional CTC populations that may be missed by other approaches are frequent in mCRPC; characterization of non‐traditional CTCs may provide additional prognostic or predictive information. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-18T21:36:19.742643-05:
      DOI: 10.1111/bju.13631
  • Risk of Hospitalization Following Primary Treatment for Prostate Cancer
    • Authors: Stephen B. Williams; Zhigang Duan, Karim Chamie, Karen E. Hoffman, Benjamin D. Smith, Jim C. Hu, Jay B. Shah, John W. Davis, Sharon H. Giordano
      Abstract: Objective To compare the risk of hospitalization and associated costs in patients following treatment for prostate cancer. Patients and Methods We identified 29,571 patients age 66–75 years without significant comorbidity from the Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database who were diagnosed with localized prostate cancer between 2004 and 2009. We compared the rates of all cause and toxicity‐related hospitalization that occurred within 1 year following initiation of definitive therapy. We used multivariable logistic regression analysis to identify determinants associated with hospitalization. Results Men who underwent surgery rather than radiotherapy had lower odds of being hospitalized for any cause following therapy (OR 0.80: 95% CI, 0.74–0.87). Patients who underwent surgery rather than radiotherapy had higher odds of being hospitalized for treatment‐related complications (OR 1.15: 95% CI, 1.03–1.29). However, men who underwent external beam radiotherapy/IMRT (OR 0.84: 95% CI, 0.72‐0.99) had 16% lower odds of hospitalization from treatment‐related complications than patients undergoing surgery. Using propensity score weighted analyses, there was no significant difference in the odds of hospitalization from treatment‐related complications for men who underwent surgery versus radiotherapy (OR 1.06: 95% CI, 0.92–1.21). Patients hospitalized for treatment‐related complications following radiotherapy were costlier than patients who underwent surgery (Mean $18,381 vs. $13,203, p
      PubDate: 2016-09-16T00:18:44.30954-05:0
      DOI: 10.1111/bju.13647
  • Long term outcome of high dose rate (HDR) brachytherapy for intermediate
           and high risk prostate cancer with a median follow up of 10 years
    • Authors: J W Yaxley; K Lah, J P Yaxley, R A Gardiner, H Samaratunga, J MacKean
      Abstract: Objective To evaluate the long term outcome of high dose rate brachytherapy (HDR) for patients with intermediate and high risk prostate cancer Subjects, Patients and Methods We retrospectively analysed the prospective longitudinal cohort data base of a single surgeon series of 507 consecutive patients treated with external beam radiotherapy and a high dose rate prostate brachytherapy boost (HDR) between August 2000 and December 2009. The risk factors are based on the D'Amico classification. We measured the incidence of biochemical freedom of recurrent prostate cancer (bNED) based on the Phoenix definition of failure (nadir + 2). We also reviewed the incidence of urethral stricture in this cohort. Results With a minimum follow up of 6 years and a median follow up of 10.3 years, the bNED for intermediate and high risk disease is 93.3 and 74.2% at 5 years respectively and 86.9% and 56.1% at 10 years. Patients with only 1 intermediate risk factor had a 10 year bNED of 94%, whereas patients with all 3 high risk factors had a 10 year bNED of 39.5%. The overall urethral stricture rate was 13.6%. Prior to 2005 the urethral stricture rate was 28.9% and after January 2005 was 4.2%. For the 271 men with a minimum follow up of 10 years the actual 10 year prostate cancer specific survival is 90.8% and actual overall survival is 86.7%. Conclusions High dose rate prostatic brachytherapy remains an appropriate treatment option for patients with intermediate or high risk prostate cancer features, who are considered not suitable for, or wish to avoid a radical prostatectomy. From December 2004, prevention strategies decreased the risk of post brachytherapy urethral strictures. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-15T09:47:32.745397-05:
      DOI: 10.1111/bju.13659
  • Prospective study comparing Videoendoscopic radical Inguinal Lymph node
           dissection (VEILND) with Open radical inguinal lymphnode dissection
           (OILND) for penile cancer over an 8 year period
    • Authors: Vivekanandan Kumar; Krishna K Sethia
      Abstract: Objectives To compare the complications and oncological outcomes between Video Endoscopic Inguinal Lymph node Dissection (VEILND) and Open Inguinal Lymph node Dissection (OILND) in men with carcinoma of the penis. Patients and methods A prospectively collected institutional database was used to determine the outcomes in 42 consecutive patients undergoing inguinal lymph node dissection between 2008 and 2015 in a centre for treating penile cancer. Before 2013 all procedures involved open surgery. Since 2013 we have performed VEILND on all patients in need of ILND. The wound related, non‐wound related complications, length of stay and oncological safety between OILND and VEILND groups were compared. The mean duration of follow up was 71months for OILND and 16 months for the VEILND groups. Results In the study period 42 patients underwent 68 inguinal node dissections (open 35, video‐assisted 33). The patients demographics, primary stage and grade, indications were comparable in both the groups. There were no intraoperative complications in either group. The wound complication rate was significantly lower in VEILND group at 6% compared to 68% in the OILND group. Lymphocele rates were similar in both the groups (27 and 20%). The VEILND group showed better or same lymph node yield, mean number of positive lymph nodes and lymph node density confirming oncological safety. There were no groin recurrence in either group of patients. VEILND patients had significant reduced length of stay by 4.9 days (p=0.0001). Conclusion VEILND is an oncologically safe procedure with considerably low morbidity and reduced length of stay at a mean follow‐up of 16 months (Range: 4‐35 months). This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-15T09:40:25.561228-05:
      DOI: 10.1111/bju.13660
  • Laparoscopic retroperitoneal partial nephrectomy using an ergonomic chair
           – demonstration of technique and matched‐pair analysis
    • Abstract: Objectives To present technique and long‐term results of retroperitoneal laparoscopic partial nephrectomy (LPN) focussing on the impact of an ergonomic platform. Patients and Methods Between January 2000 and May 2016, 287 patients (193 male, 94 female) underwent LPN by four surgeons. Median age was 59 (19‐85) years. Mean tumour size was 3.1 (1‐9) cm. Mean PADUA‐score was 7.3 (6‐12). Access was retroperitoneal in 235 (82%) cases. Since October 2010, we used ETHOSTM‐chair during excision of the tumour in 130 (45.3%) patients. 51 (17.7%) tumours were excised without ischemia and 226 (78.7%) tumours under warm ischemia with clamping of renal artery using an enucleo‐resection technique. We suture the resection bed and perform renorrhaphy using a barbed‐suture pre‐loaded with absorbable LAPRA‐TYTM‐clip. The impact of ETHOS‐chair was examined using a matched‐pair analysis (66 ETHOS vs. 67 Non‐ETHOS‐chair). Results Median operating time was 146 (60‐325) minutes. Median estimated blood loss was 99 (10 ‐ 3000) cc, mean warm ischemia time was 17.1 (7‐47) minutes. Histology showed 240 (83.6%) renal cell carcinomas and 46 (15.9%) benign tumours. Cumulative overall disease‐free survival rate after a median follow‐up of 84 (3‐155) months was 100 % for 203 pT1 renal cell tumours, local recurrence was observed in one patient (0.4%), who was managed by radical nephrectomy. There were two conversions (0.7%) to open surgery respectively to hand‐assisted laparoscopy. Perirenal hematoma was observed in 13 (4.5%) patients. 20 (6.9%) patients required transfusions (2‐11 units). We observed 5 urine leaks (1.7%) requiring prolonged drainage. Median hospital stay was 5 (3‐24) days. Three patients developed a‐v‐fistulas successfully occluded by super‐selective embolization (1.0%). Use of ETHOSTM‐chair resulted in shorter OR‐time (134.7 vs. 168.5 min., p = 0.04) including warm ischemia time (13.1 vs. 15.9 min., p=0.01) less complications (15% vs. 29.8%, p = 0.02). Limitation of the analysis is the fact that it is not prospective randomized trial. Conclusions LPN is technically difficult but oncologic effective. Standardization and simplification of endoscopic suturing using ETHOS‐chair significantly improved the outcome of the surgical procedure. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-12T22:01:01.305238-05:
      DOI: 10.1111/bju.13627
  • Perioperative and short‐term outcomes after Retzius‐sparing
           robot‐assisted radical prostatectomy stratified by gland size
    • Authors: Glen D.R Santok; Ali Abdel Raheem, Lawrence H. C. Kim, Kidon Chang, Trenton G. H. Lum, Byung H. Chung, Young D. Choi, Koon H. Rha
      Abstract: Objective o investigate the impact of preoperative prostate volume (PV) on the perioperative, continence and early oncological outcomes among patients treated with Retzius sparing robot assisted laparoscopic prostatectomy (RS‐RALP). Materials and Methods This is a retrospective analysis of 294 patients with organ‐confined prostate cancer (PCa) treated with RS‐RALP in a high volume center from November 2012 to February 2015. Patients were divided into three groups based on their TRUS volume as follows: group 1, (n=231, 60cc). Perioperative, oncological, and continence outcomes were compared between the three groups. Results The median prostate volumes for each group were; 26.1cc (22‐ 40 31), 45.9cc (41‐50) and 70cc (68‐85). Blood loss was higher in group 3 compared to group 2 and group 1; 475cc (312‐575), 200cc (150‐400) and 250cc (150‐400), respectively (p=0.001) Intraoperative transfusion rate was higher in group 3 patients (p=0.004) while complication rate did not differ (p=0.05). Console time was slightly higher but was not statistically significant in group 3 compared to groups 2 and 1; 100±35minutes, 92±34.4minutes and 93±24.8 minutes, respectively (p=0.70). BCR and continence rate did not differ between the three groups (p=0.89, p=0.25, respectively). Conclusion RS‐RALP is oncologically and functionally equivalent for all prostate sizes but technically demanding for larger prostate. We therefore recommend for surgeons to start at smaller sized prostate in the commencement of application of RS‐RALP technique. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-12T21:50:41.077391-05:
      DOI: 10.1111/bju.13632
  • Quality of life and pain relief in men with metastatic
           castration‐resistant prostate cancer on cabazitaxel: the
           non‐interventional QoLiTime study
    • Abstract: Objective To examine health‐related quality of life in men with metastatic castration‐resistant prostate cancer on cabazitaxel. Patients and methods Men with metastatic castration‐resistant prostate cancer receiving cabazitaxel (25 mg/m², every 3 weeks) and 10 mg/day oral prednis(ol)one were enrolled (2011–2014) in the non‐interventional prospective QoLiTime study. Primary outcome was change in quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30 item) with respect to PSA response after 4 cycles of cabazitaxel. Secondary outcomes included occurrence of adverse events. Results Of 527 men, 348 received 4 cycles of cabazitaxel and 266 had sufficient PSA measurements. After 4 cycles, 92 (34.6%) men had a PSA decrease ≥50% (responders). Quality of life remained stable throughout the study (P=0.62). Change in quality of life did not differ between responders and non‐responders (P=0.69). Change in PSA and global health status between baseline and 4 cycles showed an inversely proportional relationship (correlation coefficient –0.14; 95% CI –0.26 to –0.01; P=0.03), with increasing PSA corresponding to lower health status. Responders showed no change in physical functioning versus baseline (–1.75, P=0.12); non‐responders showed a reduction versus baseline (–7.00, P
      PubDate: 2016-09-12T10:30:33.313897-05:
      DOI: 10.1111/bju.13658
  • Is a negative mpMRI really able to rule out significant prostate
           cancer': The real life experience
    • Abstract: Objectives To evaluate the histopathological results after radical prostatectomy in patients that had a normal preoperative mpMRI in order to see if they had significant or insignificant disease. Moreover we evaluated the influence of the expertise of the radiologist on the results. Materials and methods We retrospectively included patients who underwent radical prostatectomy in our center and who had a preoperative negative mpMRI. The MRIs were considered negative when no suspicious lesion was seen or when the PI‐RADS V1 score was less than 7. We used pTNM stage and Gleason score on pathology reports, and whole mount sections to calculate tumor volume. Results We identified 101 patients from 2009 to 2015. Final pathology showed that 16.9% had an extraprostatic extension (EEP), 13.8% had primary Gleason pattern 4 (4+3 and up), 47.5% had secondary Gleason pattern 4 or 5, 55.9% and 20.6% had a main tumor volume ≥ 0.5mL and ≥ 2mL respectively. When limiting the analysis to expert reading only, the numbers improved: only one patient (3.4%) had an EEP (p
      PubDate: 2016-09-12T10:30:32.058433-05:
      DOI: 10.1111/bju.13657
  • A novel infusion‐drainage device to assess lower urinary tract
           function in neuro‐imaging
    • Abstract: Objective To evaluate the applicability and precision of a novel infusion‐drainage device (IDD) for standardised filling paradigms in neuro‐urology and functional magnetic resonance imaging (fMRI) studies of lower urinary tract (LUT) (dys)function. Subjects/patients and methods The IDD is based on electrohydrostatic actuation which was previously proven feasible in a prototype setup. The current design includes hydraulic cylinders and a motorised slider to provide force and motion. Methodological aspects have been assessed in a technical application laboratory as well as in healthy subjects (n=33) and patients with LUT dysfunction (n=3) undergoing fMRI during bladder stimulation. After catheterisation, the bladder was pre‐filled until a persistent desire to void was reported from each subject. The scan paradigm comprised of automated, repetitive bladder filling and withdrawal of 100 mL body warm (37° C) saline interleaved with rest and sensation rating. Neuroimaging data were analysed using Statistical Parametric Mapping 12. Results Volume delivery accuracy was between 99.1±1.2% and 99.9±0.2%, for different flowrates and volumes. MR compatibility was demonstrated with a small decrease in signal‐to‐noise ratio (SNR), i.e. 1.13% for anatomical and 0.54% for functional scans and a decrease of 1.76% for time‐variant SNR. Automated, repetitive bladder filling elicited robust (p=0.05, family‐wise error corrected) brain activity in areas previously reported to be involved in supraspinal LUT control. There was a high synchronism between the LUT stimulation and the blood oxygenation level dependent (BOLD) signal changes in such areas. Conclusion We were able to develop a magnetic resonance (MR) compatible and MR synchronised IDD to routinely stimulate the LUT during fMRI in a standardized manner. The device provides LUT stimulation at high system accuracy resulting in significant supraspinal BOLD signal changes in interoceptive and LUT control areas in congruence to the applied stimuli. The IDD is commercially available, portable, and multi‐configurable. Such a device may help to improve precision and standardization of LUT tasks in neuroimaging studies on supraspinal LUT control, and may therefore facilitate multi‐site studies and comparability between different LUT investigations in the future. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-12T10:15:29.51283-05:0
      DOI: 10.1111/bju.13655
  • PADUA and RENAL nephrometry scores correlates with perioperative outcomes
           after robot‐assisted partial nephrectomy: analysis of the Vattikuti
           Global Quality Initiative in Robotic Urologic Surgery (GQI‐RUS) database
    • Authors: Riccardo Schiavina; Giacomo Novara, Marco Borghesi, Vincenzo Ficarra, Rajesh Ahlawat, Daniel A. Moon, Francesco Porpiglia, Benjamin J. Challacombe, Prokar Dasgupta, Eugenio Brunocilla, Gaetano La Manna, Alessandro Volpe, Hema Verma, Giuseppe Martorana, Alexandre Mottrie
      Abstract: Objectives To evaluate and compare the correlations between PADUA and RENAL scores and perioperative outcomes and postoperative complications in a multicenter, international series of patients undergoing Robot‐assisted partial nephrectomy (RAPN) for masses suspicious of RCC. Patients and methods We retrospectively evaluated the clinical records of patients who underwent RAPN between 2010 and 2013 for clinical N0M0 renal tumours in four international Centers that completed all the data required for the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI‐RUS) database. All patients underwent pre‐operative computed tomography or magnetic resonance imaging to define the clinical stage and anatomic characteristics of the tumors. PADUA and RENAL scores were retrospectively assessed in each Center. Univariate and multivariate analyses were performed to evaluate the correlations between age, gender, Charlson comorbidity index, clinical tumor size, PADUA and RENAL complexity group categories and warm ischemia time >20 minutes, urinary calyceal system closure and grade of postoperative complications. Results Overall, 277 patients have been evaluated. The median tumor size was 33.0 millimeters (22.0‐43.0). The median PADUA and RENAL score were 8 and 7 respectively; 112 (40.4%), 86 (31.0%) and 79 (28.5%) patients were classified in the low, intermediate or high‐complexity group according to PADUA score, while 118 (42.5%), 139 (50.1%) and 20 (7.2%) were classified in the low, intermediate or high‐complexity group according to RENAL score, respectively. Both nephrometric tools significantly correlated with perioperative outcomes at univariate and multivariate analyses.. Conclusion A precise stratification of patients before partial nephrectomy is recommended, allowing to balance the potential threats and benefits of nephron‐sparing surgery. In our analysis, both PADUA and RENAL were significantly associated with prolonged WIT and high‐grade postoperative complications after RAPN. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-11T00:00:24.276066-05:
      DOI: 10.1111/bju.13628
  • Serum levels of enclomiphene and zuclomiphene in hypogonadal men on
           long‐term clomiphene citrate treatment
    • Authors: Sevann Helo; Joseph Mahon, Joseph Ellen, Ron Wiehle, Gregory Fontenot, Kuang Hsu, Paul Feustel, Charles Welliver, Andrew McCullough
      Abstract: Objectives To determine the relative concentrations of enclomiphene (ENC) and zuclomiphene (ZUC) isomers in hypogonadal men (HM) on long‐term clomiphene citrate (CC) therapy. To determine whether patient age, body mass index, or duration of therapy were predictive of relative concentrations of ENC and ZUC. Patients and Methods Men already on CC 25 mg daily therapy for secondary hypogonadism for a minimum of six weeks were recruited to have their ENC and ZUC levels assessed. Total testosterone (T), free testosterone, estradiol, follicle stimulating hormone (FSH), and luteinizing hormone (LH) prior to initiation of and while on CC therapy were recorded for all patients. Patient demographics including age, body mass index, and medical comorbidites were recorded. Serum samples were obtained at the time of enrollment to determine ENC and ZUC concentrations. Results A total of 15 men were enrolled from June 2015 to August 2015. Median patient age was 36 (range 22‐70) years, median body mass index 32.0 (range 21.1‐40.3)kg/m2, and median duration of treatment 25.9 (range 1.7‐86.6) months. Baseline median total T, estradiol, and LH were 205.0 ng/dL, 17.0 pg/mL, and 4.0 mlU/mL, respectively. Post‐treatment median total T, estradiol, and LH increased to 488.0 ng/dL 34.0 pg/mL, and 6.1 mIU/mL, respectively (all p
      PubDate: 2016-09-11T00:00:21.328709-05:
      DOI: 10.1111/bju.13625
  • Diagnostic accuracy of CT urography and visual assessment during
           ureterorenoscopy in upper tract urothelial carcinoma
    • Abstract: Upper tract urothelial carcinoma (UTUC) is a rare condition, although the annual incidence is increasing, possibly as a result of improved diagnostic performance and higher survival rates in patients with bladder cancer. Research data and technical development achieved in the last decades have led to a shift in the guidelines of European Association of Urology (EAU) and American Urological Association for diagnosis and treatment of UTUC. Computed tomography urography (CTU) has become the imaging of choice for investigation. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-09T07:36:46.28093-05:0
      DOI: 10.1111/bju.13652
  • The landscape of systematic reviews in urology (1998 through 2015): An
           assessment of methodologic quality
    • Authors: Julia L. Han; Shreyas Gandhi, Crystal G. Bockoven, Vikram Narayan, Philipp Dahm
      Abstract: Sir Archie Cochrane is credited with the recognition that few clinical questions in health care are appropriately addressed by consulting the results of a single study alone; instead, we should perform systematic reviews to summarize the entire body of evidence—ideally, high‐quality evidence—in order to inform patient decision‐making and health policy. His contributions provided the impetus for the founding of the Cochrane Collaboration and for the development of transparent, rigorous methods for systematic reviews. Over the last two decades, such reviews have gained increasing importance with regard to their perceived role in informing evidence‐based clinical practice. They tend to be frequently cited in the literature and thus can raise a journal's impact factor. The number of systematic reviews published in the urology literature has clearly increased. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-09T04:21:15.537585-05:
      DOI: 10.1111/bju.13653
  • A Qualitative Study on Decision‐Making by Prostate Cancer Physicians
           during Active Surveillance
    • Authors: Stacy Loeb; Caitlin Curnyn, Angela Fagerlin, R. Scott Braithwaite, Mark D. Schwartz, Herbert Lepor, H. Ballentine Carter, Erica Sedlander
      Abstract: Objective To explore and identify factors that influence physicians’ decisions while monitoring prostate cancer patients on active surveillance. Subjects and methods A purposive sampling strategy was used to identify physicians treating prostate cancer from diverse clinical backgrounds and geographic areas across the US. We conducted 24 in‐depth interviews from July‐December 2015, until thematic saturation was reached. The Applied Thematic Analysis framework was used to guide data collection and analysis. Interview transcripts were reviewed and coded independently by two researchers. Matrix analysis and NVivo software was used for organization and further analysis. Results Eight key themes emerged to explain variation in active surveillance monitoring: 1) physician comfort with active surveillance, 2) protocol selection, 3) beliefs about the utility and quality of testing, 4) years of experience and exposure to AS during training, 5) concerns about inflicting “harm”, 6) patient characteristics, 7) patient preferences, and 8) financial incentives. Conclusion These qualitative data reveal which factors influence physicians that manage patients on AS. There is tension between providing standardized care while also considering individual patients’ needs and health status. Additional education on active surveillance is needed during urology training and continuing medical education. Future research is needed to empirically understand whether any specific protocol is superior to tailored, individualized care. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-09T02:50:59.225621-05:
      DOI: 10.1111/bju.13651
  • Pathologic Analysis of the Prostatic Anterior Fat Pad at the time of
           Radical Prostatectomy: Insights from a Prospective Series
    • Authors: Mark W. Ball; Kelly T. Harris, Zeyad Schwen, Jeffrey K Mullins, Misop Han, Patrick C. Walsh, Alan W. Partin, Jonathan I. Epstein
      Abstract: Objective To assess factors associated with lymphatic drainage and lymph node metastasis to the prostatic anterior fat pad (PAFP) in men with prostate cancer and the utility of routine PAFP analysis at the time of radical prostatectomy (RP). Methods Our institution began to prospectively collect PAFP tissue in 2010. The PAFP was removed at the time of RP and sent as a pathologic specimen separate from the pelvic LNs and prostate. Consecutive RPs performed at our institution in which the PAFP was removed were reviewed to determine the rate of LNs in the PAFP, the rate of metastatic LNs in the PAFP, and the association of metastatic PAFP LN with clinical and pathologic features. The impact on biochemical recurrence was assessed with a Cox's proportional hazard model. Results In total, 2,413 AFP specimens were available for analysis. LNs were found in the AFP in 255(10.6%) cases and metastatic LNs to the PAFP were found in 14 (0.6%) cases. Metastatic PAFP LNs were associated with anterior tumors in 11 (78.6%) cases (p = 0.01), and were present only in pre‐operative D'Amico intermediate‐ (n=6, 42.8%) and high‐ (n=8, 57.1%) risk patients (p < 0.001). Metastatic PAFP LNs were associated with extraprostatic disease in 13 (92.8%) of cases, though concomitant pelvic LN involvement was present in only 4 (28.6%) cases. With a mean follow up of 1.5 years, 3 (21.4%) patients with metastatic PAFP LN experienced BCR. Positive LN involvement in either the pelvic LN or PAFP had worse BCR than LN negative patients (p < 0.0001); however, there was no difference in BCR between patients with positive pelvic LN and positive PAFP LN (p=0.5). Conclusion Metastatic PAFP LNs are rare and always occur in the presence of other adverse pathologic features. The routine pathologic analysis of PAFP as a separate specimen, especially in low‐risk disease, may not be warranted. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-09T02:50:57.770637-05:
      DOI: 10.1111/bju.13654
  • Lesion volume predicts prostate cancer risk and aggressiveness: validation
           of its value alone and matched with PIRADS score
    • Authors: Eugenio Martorana; Giacomo Maria Pirola, Michele Scialpi, Salvatore Micali, Andrea Iseppi, Luca Reggiani Bonetti, Shaniko Kaleci, Pietro Torricelli, Giampaolo Bianchi
      Abstract: Objective To demonstrate the association between MRI estimated lesion volume (LV), PCa detection and tumour clinical significance evaluating this variable alone and matched with PI‐RADSv2 score. Patients and methods We retrospectively analysed 157 consecutive patients, with at least one prior negative systematic prostatic biopsy, who underwent transperineal MRI/US fusion targeted biopsy (Tp MRI/US FTB) between January 2014 and February 2016 using Biopsee® system. Suspicious lesions (SL) were bordered using a “region of interest” and the system calculated prostate volume and LV. Patients were divided in groups considering LV (< 0.5 ml, 0.5 ‐ 1 ml, > 1 ml) and PI‐RADS score (1‐5). We considered as clinically significant PCa (sPCa) all cancers with GS ≥ 3 + 4 as suggested by PI‐RADS v2. A direct comparison between MRI estimated LV (MRI LV) and histological tumour volume (HTV) was done in 23 patients who underwent radical prostatectomy during the study period. Differences between MRI LV and HTV were assessed using the paired sample t test. MRI LV volume and HTV concordance was verified using a Bland‐Altman plot. Chi‐square test, logistic and ordinal regression model were used to evaluate difference in frequencies. The selected level of statistical significance was ≤ 0.05. Results The LV and PI‐RADS score were associated both with PCa detection (p < 0.00001 and p= 0.00012) and with sPCa detection (p< 0.00001 and p= 0.00808). When the two variables were matched, LV increased the risk within each PI‐RADS group. PCa detection became 1.4 times higher for LV 0.5 ‐ 1 ml and 1.8 times higher for LV > 1 ml; sPCa detection increased 2.6 times for LV 0.5 ‐ 1 ml and 4 times for LV > 1ml. There was positive correlation between MRI LV and HTV (r = 0,9876, p < 0.001). Finally, Bland‐Altman analysis showed that MRI LV was underestimated by 4.2% compared to HTV. Study limitations are its monocentric and retrospective design and the limited casistic. Conclusions This study demonstrates that PIRADS score and the LV, independently and matched, are associated with PCa detection and with tumour clinical significance. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-08T13:50:20.096471-05:
      DOI: 10.1111/bju.13649
  • The influence of prostate‐specific antigen density on positive and
           negative predictive values of multiparametric magnetic resonance imaging
    • Authors: Nienke L. Hansen; Tristan Barrett, Brendan Koo, Andrew Doble, Vincent Gnanapragasam, Anne Warren, Christof Kastner, Ola Bratt
      Abstract: Objectives To evaluate the influence of PSA‐D on positive (PPV) and negative (NPV) predictive values of mpMRI to detect GS ≥7 cancer in a repeat biopsy setting. Patients and methods Retrospective study of 514 men with previous prostate biopsy showing no or GS 6 cancer. All had mpMRI, graded 1‐5 on a Likert scale for cancer suspicion, and subsequent targeted and 24‐core systematic image‐fusion guided transperineal biopsy in 2013‐2015. NPVs and PPVs of mpMRIs for detecting GS ≥7 cancer were calculated (±95% confidence intervals) for PSA‐D ≤0.1, 0.1‐0.2, ≤0.2 and >0.2 ng/ml/cm3, and compared by Chi‐square test for linear trend. Results GS ≥7 cancer was detected in 31% of the men. NPV of Likert 1‐2 mpMRI was 0.91 (±0.04) with PSA‐D ≤0.2 and 0.71 (±0.16) with >0.2 (p=0.003). For Likert 3 mpMRI, PPV was 0.09 (±0.06) with PSA‐D ≤0.2 and 0.44 (±0.19) with >0.2 (p=0.002). PSA‐D also significantly affected the PPV of Likert 4‐5 mpMRI lesions: the PPV was 0.47 (±0.08) with PSA‐D ≤0.2 and 0.66 (±0.10) with >0.2 (p=0.0001). Conclusion In a repeat biopsy setting, PSA‐D ≤0.2 is associated with low detection of GS ≥7 prostate cancer, not only in men with negative mpMRI, but also in men with equivocal imaging. Surveillance, rather than repeat biopsy, may be appropriate for these men. Conversely, biopsies are indicated in men with high PSA‐D, even if an mpMRI shows no suspicious lesion, and in men with an mpMRI suspicious for cancer, even if PSA‐D is low. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-08T12:50:27.269121-05:
      DOI: 10.1111/bju.13619
  • Safety, reliability and accuracy of small renal tumor biopsies: Results of
           a multi‐institution registry
    • Abstract: Objective To validate the safety, accuracy and reliability of RTB and its role in decreasing unnecessary treatment in a multi‐institution review. Materials and methods This was a multi‐institution retrospective study of patients who underwent RTB to characterize a SRM between 2011 and May 2015. Subjects were identified using the prospectively maintained Canadian Kidney Cancer information system (CKCis). Diagnostic and concordance rates were presented using proportions whereas factors associated with a diagnostic RTB were identified using a logistic regression model. Results Of the 373 biopsied SRMs, the initial biopsy was diagnostic in 87% of cases. Of the 47 nondiagnostic biopsies, 15 had a repeat biopsy of which, 80% were diagnostic. Therefore, when both were combined, a diagnosis was obtained in 91% of SRMs. Of these, 18% were benign. Size was the only factor found to be associated with achieving a diagnostic biopsy. RTB histology and nuclear grade (high or low) were found to be highly concordant with surgical pathology (86% and 81%, respectively). Of the discordant tumors (n=16), all were upgraded from low to high grade on surgical pathology. Adverse events were rare (
      PubDate: 2016-09-07T03:40:22.747368-05:
      DOI: 10.1111/bju.13630
  • Randomised trial of early infant circumcision performed by clinical
           officers and registered nurse midwives using the Mogen clamp in Rakai,
    • Authors: Edward N. Kankaka; Teddy Murungi, Godfrey Kigozi, Frederick Makumbi, Dorean Nabukalu, Stephen Watya, Nehemiah Kighoma, Resty Nampijja, Daniel Kayiwa, Fred Nalugoda, David Serwadda, Maria Wawer, Ronald H. Gray
      Abstract: Objectives To assess the safety and acceptability of early infant circumcision (EIC) provided by trained clinical officers (COs) and registered nurse midwives (RNMWs) in rural Uganda. Subjects and Methods We conducted a randomised trial of EIC using the Mogen clamp provided by newly trained COs and RNMWs in four health centres in rural Rakai, Uganda. The trial was registered with # NCT02596282. In all, 501 healthy neonates aged 1–28 days with normal birth weight and gestational age were randomised to COs (n = 256) and RNMWs (n = 245) for EIC, and were followed‐up at 1, 7 and 28 days. Results In all, 701 mothers were directly invited to participate in the trial, 525 consented to circumcision (74.9%) and 23 were found ineligible on screening (4.4%). The procedure took an average of 10.5 min. Adherence to follow‐up was >90% at all scheduled visits. The rates of moderate/severe adverse events were 2.4% for COs and 1.6% for RNMWs (P = 0.9). All wounds were healed by 28 days after circumcision. Maternal satisfaction with the procedure was 99.6% for infants circumcised by COs and 100% among infants circumcised by RNMWs. Conclusions EIC was acceptable in this rural Ugandan population and can be safely performed by RNMWs who have direct contact with the mothers during pregnancy and delivery. EIC services should be made available to parents who are interested in the service.
      PubDate: 2016-09-06T00:50:47.727872-05:
      DOI: 10.1111/bju.13589
  • Prostate cancer outcomes for men who present with symptoms at diagnosis
    • Authors: Kerri R. Beckmann; Michael E. O'Callaghan, Rasa Ruseckaite, Ned Kinnear, Caroline Miller, Sue Evans, David M. Roder, Kim Moretti,
      Abstract: Objective To compare clinical features, treatments and outcomes in men with non‐metastatic prostate cancer (PCa) according to whether they were referred for symptoms or elevated prostate specific antigen (PSA). Patients and methods This study used data from the South Australia Prostate Cancer Clinical Outcomes Collaborative database; a multi‐institutional clinical registry covering both the public and private sectors. Participants included all non‐metastatic cases from 1998‐2013 referred for urinary/prostatic symptoms or elevated PSA. Multivariate Poisson regression was used to identify characteristics associated with symptomatic presentation and compare treatments according to reason for referral. Outcomes (i.e. overall survival, PCa survival, metastatic‐free survival and disease‐free survival) were compared using multivariate Cox proportional hazards and competing risk regression. Results Our analytic cohort consisted of 4841 men with localised PCa. Symptomatic men had lower risk disease (IR= 0.70, CI 0.61‐0.81 for high vs low risk), fewer radical prostatectomies (IR=0.64 CI 0.56‐0.75) and less radiotherapy (IR=0.86, CI 0.77‐0.96) than men presenting with elevated PSA. All‐cause mortality (HR=1.31, CI 1.16‐1.47), disease‐specific mortality (HR=1.42, CI 1.13‐1.77) and risk of metastases (HR=1.36, CI 1.13‐1.64) were higher for men presenting with symptoms, after adjustment for other clinical characteristics. However, risk of disease progression did not differ (HR=0.90, CI 0.74‐1.07) amongst those treated curatively. Subgroup analyses indicated poorer PCa survival for symptomatic referral among men undergoing radical prostatectomy (HR=3.4, CI 1.3‐8.8), those over 70 years (HR=1.4, CI 1.0‐1.8), private patients (HR=2.1, CI 1.3‐3.3), those diagnosed via biopsy (HR=1.3, CI 1.0‐1.7) and those diagnosed before 2006 (HR=1.6, CI 1.1.2‐1.7). Conclusion Our results suggest that symptomatic presentation may be an independent negative prognostic indicator for PCa survival. More complete assessment of disease grade and extent, more definitive treatment and increased post‐treatment monitoring among symptomatic cases may improve outcomes. Further research to determine any pathophysiological basis for poor outcomes in symptomatic men is warranted. This article is protected by copyright. All rights reserved.
      PubDate: 2016-09-03T22:20:28.085435-05:
      DOI: 10.1111/bju.13622
  • Value of 3‐T multiparametric magnetic resonance imaging and targeted
           biopsy for improved risk stratification in patients considered for active
    • Authors: Rodrigo R. Pessoa; Publio C. Viana, Romulo L. Mattedi, Giuliano B. Guglielmetti, Mauricio D. Cordeiro, Rafael F. Coelho, William C. Nahas, Miguel Srougi
      Abstract: Objective To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) of the prostate and transrectal guided biopsy (TRUS‐Bx) with visual estimation in early risk stratification of patients on active surveillance. Patients and methods patients with low‐risk, low‐grade, localized prostate cancer (PCa) were prospectively enrolled and submitted to a 3T 16‐channel cardiac surface coil mpMRI of the prostate and confirmatory biopsy (CB), which included a standard biopsy (SB) and visual estimation‐guided TRUS‐Bx. Cancer‐suspicious regions (CSRs) were defined using Prostate Imaging Reporting and Data System (PI‐RADS) scores. Reclassification occurred if CB confirmed the presence of a Gleason score ≥7, greater than three positive fragments, or ≥50% involvement of any core. The performance of mpMRI for the prediction of CB results was assessed. Univariate and multivariate logistic regressions were performed to study relationships between age, PSA, PSA density (PSAd), number of positive cores in the initial biopsy, and mpMRI grade on CB reclassification. Our report is consistent with START guidelines. Results a total of 105 patients were available for analysis in the study. From this cohort, 42 (40%) had PI‐RADS 1, 2, or 3 lesions and 63 (60%) had only grade 4 or 5 lesions. Overall, 87 patients underwent visual estimation TRUS‐Bx. Reclassification among patients with PI‐RADS 1, 2, 3, 4, and 5 was 0%, 23.1%, 9.1%, 74.5%, and 100%, respectively. Overall, mpMRI sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for disease reclassification were 92.5%, 76%, 81%, and 90.5%, respectively. In the multivariate analysis, only PSAd and mpMRI remained significant for reclassification (p
      PubDate: 2016-09-03T22:20:25.78864-05:0
      DOI: 10.1111/bju.13624
  • Metastatic Potential to Regional Lymph Nodes with Gleason Score ≤7
           including Tertiary Pattern 5 at Radical Prostatectomy
    • Authors: Mairo L. Diolombi; Jonathan I. Epstein
      Abstract: Objectives  To determine the risk of pelvic LN metastases at radical prostatectomy (RP) with GS ≤7: 3+3=6 (GG1); 3+4=7 (GG2); 3+4=7 (GG2) with tertiary pattern 5 (T5); 4+3=7 (GG3); 4+3=7 (GG3) with T5 using the 2014 Modified Gleason grading system and the novel Grade Group (GG) system. Materials and Methods  We searched our RP database between 2005 and 2014 for cases of GS ≤7 with simultaneous pelvic LN dissection (PLND). Since 2005, we have graded all glomeruloid and cribriform cancer as Gleason pattern 4 and graded mucinous adenocarcinoma based on the underlying architectural pattern consistent with the 2014 Modified Gleason grading system. All RPs were embedded in entirety, including the PLND. A total of 7442 cases were identified, of which 73 had at least 1 positive LN (+LN). Results  The incidence of regional LN metastases at RP for 3+3=6 (GG1); 3+4=7 (GG2); 3+4=7 (GG2) with T5; 4+3=7 (GG3); 4+3=7 (GG3) with T5 were 0%, 0.6%, 0.4%, 4.3% and 6.3% respectively. There was a statistically significant difference in risk of +LN at RP between the Grade Groups as defined by the novel Grade Group system. There was no statistically significant difference in risk of +LN at RP for men with 3+4 (GG2) vs. 3+4 (GG2) with T5 and for men with 4+3 (GG3) vs. 4+3 (GG3) with T5. Non‐pelvic LN involvement was identified in 0.2% of all RPs. Two patients with Gleason score 3+4=7 with
      PubDate: 2016-09-02T22:40:24.93675-05:0
      DOI: 10.1111/bju.13623
  • Surgical quality of minimally invasive adrenalectomy for adrenocortical
           carcinoma: a contemporary analysis using the national cancer data base
    • Authors: Matthew J. Maurice; Matthew J. Bream, Simon P. Kim, Robert Abouassaly
      Abstract: Objectives To compare quality outcomes between open (OA) and minimally invasive (MIA) adrenalectomy for adrenocortical carcinoma. Patients and Methods In the National Cancer Data Base, we identified 481 patients with non‐metastatic adrenocortical carcinoma who underwent adrenalectomy from 2010‐2013. OA and MIA were compared on positive‐surgical‐margin and lymphadenectomy rates (primary outcomes) and lymph node yield, length of stay, readmission, and overall survival (secondary outcomes). Using the intention‐to‐treat principle, minimally‐invasive‐converted‐to‐open cases were considered MIA. Logistic regression analysis was used to identify predictors of positive margins and lymphadenectomy. Associations between approach and the outcomes were further assessed by stage and tumor size. Results Overall, 161 patients (33.5%) underwent MIA. MIA was used more commonly in older, comorbid patients; for smaller, localized tumors; and at lower‐volume centers. In the intention‐to‐treat analysis, MIA independently predicted positive margins (OR 2.0, 95%CI 1.1‐3.6, p=.03) and no lymphadenectomy (OR 0.1, 95%CI 0.03‐0.6, p=.01). On subgroup analysis, the association between MIA and positive margins only held true for pT3 disease (48.7% vs. 26.7%, p=.01). A higher rate of margin positivity was observed for tumors ≥10 cm managed with MIA vs. OA, but this difference was not significant (28.2% vs. 18.5%, p=.16). Likewise, the association between MIA and no lymphadenectomy was only observed for male patients, tumors ≥10 cm, and cN0 disease. After excluding minimally‐invasive‐converted‐to‐open cases, the difference in margin positivity was less pronounced and non‐significant (OR 1.8, 95%CI 0.9‐3.4, p=.08). MIA was associated with significantly shorter median length of stay (3 vs. 6 days, p
      PubDate: 2016-09-01T00:15:23.627576-05:
      DOI: 10.1111/bju.13618
  • Renal fossa recurrence following nephrectomy for renal cell carcinoma:
           prognostic features and oncologic outcomes
    • Abstract: Objective To describe clinicopathologic features associated with increased risk of renal fossa recurrences (RFR) following radical nephrectomy (RN) and to describe prognostic features associated with cancer‐specific survival (CSS) among patients with RFR treated with primarily locally‐directed therapy, systemically directed therapy, or expectant management. Patients And Methods Records of 2502 patients treated with RN for unilateral, sporadic, localized RCC between 1970 and 2006 were reviewed. CSS following RFR was estimated using the Kaplan‐Meier method. Associations with the development of RFR and CSS following RFR were evaluated using Cox proportional hazards regression models. Results A total of 33 (1.3%) patients developed isolated RFR (iRFR) and 30 (1.2%) patients developed RFR in the setting of synchronous metastases following RN (study cohort, N=63). Median follow‐up for the series was 9.0 years after RN and 6.0 years following RFR diagnosis. On multivariable analysis, advanced pathologic stage (pT2: HR 4.36, p=0.004; pT3/4: HR 4.39, p=0.003) and coagulative necrosis (HR 2.71, p=0.006) were independently associated with increased risk of iRFR. The median time to recurrence was 1.5 years post‐nephrectomy among the 33 patients with iRFR, and 1.4 years among all patients. Overall, median CSS was 2.5 years after iRFR diagnosis, 1.3 years after RFR in the setting of synchronous metastases, and 2.2 years overall. Following primary locally directed therapy (surgery, ablation, or radiation), systemic therapy, or expectant management, the 3‐year CSS rates among patients with iRFR were 63%, 50%, and 13% (p=0.001) and were 64%, 50%, and 28% (p=0.006) among all patients,respectively. On multivariable analysis, when compared to observation, locally directed therapies were associated with a significantly decreased risk of death from RCC (HR 0.26, p
      PubDate: 2016-08-31T22:25:24.890225-05:
      DOI: 10.1111/bju.13620
  • Selective Arterial Clamping Does Not Improve Outcomes in Robotic Partial
           Nephrectomy; A Propensity Score Analysis Of Patients Without Impaired
           Renal Function
    • Authors: David J. Paulucci; Daniel C. Rosen, John P. Sfakianos, Michael J. Whalen, Ronney Abaza, Daniel D. Eun, Louis S. Krane, Ashok K. Hemal, Ketan K. Badani
      Abstract: Objectives To assess the benefit of selective arterial clamping (SAC) as an alternative to main renal artery clamping (MAC) during robotic partial nephrectomy (RPN) in patients without underlying chronic kidney disease. Subjects/Patients and Methods Our study cohort comprised 665 patients without impaired renal function undergoing MAC (n=589) and SAC (n=76) RPN respectively from four medical institutions from 2008‐2015. We compared complication rates, positive surgical margin (PSM) rates, and perioperative and intermediate term renal functional outcome between 132 MAC and 66 SAC patients after 2 to 1 nearest neighbor propensity score matching for age, sex, BMI, R.E.N.A.L. Nephrometry score, tumor size, baseline eGFR, ASA, Charlson Comorbidity Index (CCI), and warm ischemia time (WIT). Results In propensity matched patients, PSM (5.7% vs. 3.0%, p=.407) and complications (13.8% vs. 10.6%, p=.727) did not differ for MAC vs. SAC. Incidence of acute kidney injury in MAC vs. SAC (25.0% vs. 32.0%, p=.315) within the first 30 days was similar. At median follow‐up of 7.5 months, the percentage reduction in eGFR (‐9.3% vs. ‐10.4%, p=.518) and progression to CKD ≥ Stage 3 (7.2% vs. 8.5%, p=.792) showed no difference. Conclusions Our study findings show no difference in PSM, complications, nor intermediate term renal functional outcomes in patients with unimpaired renal function with SAC compared to MAC. When expected WIT is low, routine utilization of SAC may not be necessary. Further studies will need to determine the role of SAC in solitary kidney patients or in patients with significantly impaired renal function. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-31T22:20:24.904237-05:
      DOI: 10.1111/bju.13614
  • Management of Radiation Therapy Oncology Group (RTOG) grade 4 urinary
           adverse events (UAEs) from radiotherapy for prostate cancer
    • Authors: Erik N. Mayer; Jonathan D. Tward, Mitchell Bassett, Sara M. Lenherr, James M. Hotaling, William O. Brant, William T. Lowrance, Jeremy B. Myers
      Abstract: Objective To describe the management of grade 4 Radiation Therapy Oncology Group (RTOG) urinary adverse events (UAEs) after radiotherapy (RT) for prostate cancer (PCa). We hypothesized grade 4 UAEs often require complex surgical management and subject patients to significant morbidity. Methods A single‐center retrospective review, over a 6‐year period (2010‐2015), identified men with RTOG grade 4 UAEs after RT for PCa. RT was classified as combined modality therapy (radical prostatectomy (RP) followed by external beam radiotherapy (EBRT), EBRT + low‐dose brachytherapy (LDR), EBRT + high‐dose brachytherapy (HDR), or other combinations of RT) or single modality RT. UAEs were classified as outlet (urethral stricture, bladder neck contracture, prostate necrosis, or recto‐urethral fistula) or bladder (contraction, necrosis, fistula, ureteral stricture, or hemorrhage). Results We identified 73 men with a mean age of 73 years. Forty‐four (60%) had combined modality therapy, consisting of RP + EBRT (19), high dose rate brachytherapy (HDR) + EBRT (19), low dose rate brachytherapy (LDR) + EBRT (5), and other combined modality RT (2). Twenty‐nine (40%) patients had single modality therapy consisting of EBRT (4), HDR (11), LDR (12), or proton beam (2). UAEs were isolated to the bladder in 6 (8%), the outlet in 52 (71%), and both in 15 (21%). UAE management included: conservative in 21 (29%), indwelling catheters in 12 (16%), reconstructive in 19 (26%), and urinary diversion in 23 (32%). Reconstruction included: ureteral (4), recto‐urethral fistula repair (2), and posterior urethroplasty (13), of which 14/16 (88%) surgeries with follow‐up >90 days were successful. Conclusions Although the incidence of RTOG grade 4 UAEs after PCa radiation treatment is not well defined, their morbidity is significant, and approximately one third of patients with these high‐grade complications require urinary diversion. Conversely only about a quarter of patients can be managed with conservative strategies or local surgeries. Reconstruction is successful in selected patients. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-30T02:10:44.94212-05:0
      DOI: 10.1111/bju.13607
  • Risk Prediction Tool for Grade Reclassification in Favorable‐Risk
           Men on Active Surveillance
    • Authors: Mufaddal M. Mamawala; Karthik Rao, Patricia Landis, Jonathan I. Epstein, Bruce J. Trock, Jeffrey J. Tosoian, Kenneth J. Pienta, H. Ballentine Carter
      Abstract: Objective To create a nomogram for men on active surveillance (AS) for prediction of grade reclassification (GR) above Gleason score 6 (Grade group >2) at surveillance biopsy. Materials and Methods From a cohort of men enrolled in an AS program, a multivariable model was used to identify clinical and pathologic parameters predictive of GR. Nomogram performance was assessed using receiver operating characteristic curves, calibration and decision curve analysis. Results Of 1374 men, 254 (18.50%) were reclassified to Gleason 7 or higher on surveillance prostate biopsy. Variables predictive of GR were earlier year of diagnosis (≤2004 vs. ≥2005; odds ratio [OR] = 2.16, P = < 0.0001), older age (OR = 1.05, P = 0.0004), higher prostate specific antigen density [PSAD] (OR = 1.19 [per 0.1 unit increase], P = 0.04), bilateral disease (OR = 2.86, P = < 0.0001), risk strata (low‐risk vs. very‐low‐risk, OR=1.79, P = 0.0009) and total number of biopsies without GR (OR = 0.68, P = < 0.0001). On internal validation, a nomogram created using the multivariable model demonstrated an area under the curve of 0.757 (95% CI = 0.730, 0.797) for predicting GR at the time of next surveillance biopsy. Conclusion The nomogram described is currently being used at each return visit to assess the need for a surveillance biopsy, and could increase retention in AS. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-29T11:40:23.026279-05:
      DOI: 10.1111/bju.13608
  • The Role of Biobanking in Urology: A Review
    • Authors: Heather J. Chalfin; Elizabeth Fabian, Leslie Mangold, David B. Yeater, Kenneth J. Pienta, Alan W. Partin
      Abstract: In the current era of individualized medicine, a biorepository of human samples is essential to support clinical and translational research. There have been limited efforts in this arena within the field of urology, as costs, logistical, and ethical issues represent significant deterrents to biobanking. The Johns Hopkins Brady Urological Institute (JHBUI) Biorepository was founded in 1994 as a resource to facilitate discovery. Since its inception, the biorepository has enabled numerous research endeavors including pivotal trials leading to the regulatory approval of four diagnostic tests for prostate cancer. In this review, we discuss the current state of biobanking within urology, outline the specific ethical and financial challenges of biobanking as well as solutions, and describe the operations of a successful urologic biorepository. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-29T11:35:32.01481-05:0
      DOI: 10.1111/bju.13606
  • The actual lowering effect of metabolic syndrome on serum
           prostate‐specific antigen levels is partly concealed by enlarged
           prostate: results from a large‐scale population‐based study
    • Authors: Sicong Zhao; Ming Xia, Jianchun Tang, Yong Yan
      Abstract: Objectives To clarify the actual lowering effect of metabolic syndrome (MetS) on serum prostate‐specific antigen (PSA) levels in a Chinese‐screened population. Materials and Methods A total of 45,540 ostensibly healthy men aged 55‐69 years of old who underwent routine health check‐ups at Beijing Shijitan Hospital from 2008 to 2015 were included in this study. All subjects underwent detailed clinical evaluations. PSA mass density was calculated (serum PSA level × plasma volume ÷ prostate volume) for simultaneously adjusting plasma volume and prostate volume. According to the modified NCEP‐ATP III criteria, subjects were dichotomized by the presence of MetS, and the differences in PSA density and PSA mass density were compared between groups. Linear regression analysis was used to evaluate the effect of MetS on serum PSA levels. Results When larger prostate volume in men with MetS was adjusted, both the PSA density and PSA mass density in subjects with MetS were significantly lower than that in subjects without MetS, and the estimated difference in mean serum PSA level between subjects with and without MetS was greater than that before prostate volume was adjusted. In multivariate regression model, the presence of MetS was independently associated with an 11.3% decline in serum PSA levels compared with subjects without MetS. In addition, the increasing number of positive MetS components was significantly and linearly associated with the declining in serum PSA levels. Conclusion The actual lowering effect of MetS on serum PSA levels was partly concealed by the enlarged prostate in men with MetS, and the presence of MetS was independently associated with lower serum PSA levels. Urologists need to be aware of the effect of MetS on serum PSA levels and discuss this subject with their patients. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-28T21:45:25.745517-05:
      DOI: 10.1111/bju.13621
  • Oncologic outcomes and complication rates after laparoscopic‐assisted
           cryoablation: a EuRECA multi‐institutional study
    • Abstract: Objective To assess complication rates and intermediate oncologic outcomes of laparoscopic‐assisted cryoablation (LCA) in patients with small renal masses (SRM). Patients and Methods A retrospective review of 808 patients treated with LCA for T1a renal masses from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien‐Dindo classification. Kaplan‐Meier analyses were used to estimate 5 and 10‐year disease‐free survival (DFS) and overall survival (OS). Results Median age was 67 years (IQR: 58‐74). Median tumour size was 25mm (IQR: 19‐30). The transperitoneal approach was used in 77.7% of the patients. Median postoperative hospital stay was two days. A total of 514 patients with a biopsy‐confirmed RCC were available for survival analyses. Median follow‐up time for the RCC‐cohort was 36 months (IQR: 14‐56). A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5/10‐year DFS was 90.4%/80.0% and 5/10‐year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥ 3) in 26 patients (3.2%). An ASA score of three was associated with an increased risk of overall complications (OR: 2.85; 95%CI: 1.32‐6.20; p=0.005). Conclusions This large series of LCA demonstrates satisfactory long‐term oncologic outcomes for SRMs. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-26T03:00:33.501699-05:
      DOI: 10.1111/bju.13615
  • Prostate size, nocturia, and the digital rectal exam: a cohort study of
           30,500 men
    • Authors: Benjamin V. Stone; Jonathan Shoag, Joshua A. Halpern, Sameer Mittal, Patrick Lewicki, David M. Golombos, Dina Bedretdinova, Bilal Chughtai, Christopher E. Barbieri, Richard K. Lee
      Abstract: Objectives To evaluate the utility of the digital rectal exam (DRE) in estimating prostate size and the association of DRE with nocturia in a population‐based cohort. Subjects and Methods We identified all men randomized to the screening arm of the PLCO trial for whom DRE results were available. Subjects were excluded with history of prostate surgery or incident prostate cancer. Prostate posterior surface area was derived from DRE sagittal and transverse estimates. Relationships between prostate posterior surface area, transrectal ultrasound (TRUS), PSA, and nocturia were analyzed using intraclass correlation coefficient (ICC), Spearman's rank correlation, and multivariable logistic regression. Results 30,500 men met inclusion criteria, with 103,275 screening visits containing paired DRE and PSA data. DRE posterior surface area estimates had an ICC of 0.547 (95% CI 0.541‐0.554) and were significantly yet modestly correlated with increased prostate‐specific antigen (rs=0.18, p
      PubDate: 2016-08-23T21:45:32.692036-05:
      DOI: 10.1111/bju.13613
  • COX‐2 Inhibition for Prostate Cancer Chemoprevention: Double‐Blind
           Randomized Study of Pre‐Prostatectomy Celecoxib or Placebo
    • Authors: Jason F. Flamiatos; Tomasz M. Beer, Julie N. Graff, Kristine M. Eilers, Wei Tian, Harman S. Sekhon, Mark Garzotto
      Abstract: Objective To evaluate the biologic effects of selective cyclooxygenase‐2 inhibition on prostate tissue in men undergoing prostatectomy. Materials and Methods Patients with localized prostate cancer were randomized to receive either celecoxib 400 mg twice daily or placebo for four weeks prior to prostatectomy. Specimens were analyzed for levels of apoptosis, prostaglandins, and androgen receptor. Effects on serum prostate‐specific antigen (PSA) and post‐operative opioid use were also measured. Results Twenty‐eight of 44 anticipated patients enrolled and completed treatment. One patient on the celecoxib arm had a myocardial infarction post‐operatively. For this reason, and safety concerns in other studies, enrollment was halted. The apoptosis index in tumor cells was 0.29% (95% CI: 0.11‐0.47%) versus 0.39% (95% CI: 0.00‐0.84%) in the celecoxib and placebo arms, respectively (p=0.68). The apoptosis index in benign cells was 0.18% (95% CI: 0.03‐0.32%) versus 0.13% (95% CI: 0.00‐0.28%) in the celecoxib and placebo arms, respectively (p=0.67). PGE2 and androgen receptor levels were similar in cancer and benign tissues when comparing the two arms. Median baseline PSA was 6.0ng/ml and 6.2ng/ml for the celecoxib and placebo groups, respectively, and did not significantly change after celecoxib treatment. There was no difference in post‐operative opiate usage between arms. Conclusion Celecoxib had no effect on apoptosis, prostaglandins or androgen receptor levels in cancerous or benign prostate tissues. These findings coupled with drug safety concerns should serve to limit interest in these selective drugs as chemopreventive agents. This article is protected by copyright. All rights reserved.
      PubDate: 2016-08-23T21:45:27.390728-05:
      DOI: 10.1111/bju.13612
  • Comparison of robot‐assisted and open partial nephrectomy for completely
           endophytic renal tumours: a single centre experience
    • Authors: Onder Kara; Matthew J. Maurice, Ercan Malkoc, Daniel Ramirez, Ryan J. Nelson, Peter A. Caputo, Robert J. Stein, Jihad H. Kaouk
      Abstract: Objective To compare outcomes between robot‐assisted partial nephrectomy (RAPN) and open PN (OPN) for completely endophytic renal tumours. Patients and Methods We retrospectively reviewed 1 230 consecutive cases, consisting of 823 RAPNs and 407 OPNs, performed for renal mass at a single academic tertiary centre between 2011 and 2016. Of these, data on 87 RAPN and 56 OPN cases for completely endophytic renal tumours were analysed. Patient and tumour characteristics, operative, postoperative, functional, and oncological outcomes were compared between groups. Results Apart from a higher prevalence of solitary kidney among OPN cases (RAPN, 5.7% vs OPN, 21.4%; P = 0.005), demographic characteristics were similar between the groups. There were no statistically significant differences in tumour size (P = 0.07), tumour stage (P = 0.3), margin status (P = 0.48), malignant tumour subtypes (P = 0.51), and grades (P = 0.61) between the groups. Also, there were no statistically significant differences among the groups for warm ischaemia time (P = 0.15), cold ischaemia time (P = 0.28), and intraoperative (P = 0.75) or postoperative (Clavien–Dindo Grade I–V, P = 0.08; Clavien–Dindo Grade III–V, P = 0.85) complication rates. The patients in the RAPN group had a shorter length of stay (P < 0.001), less estimated blood loss (P < 0.001), and lower intraoperative transfusion rates (0% vs 7.1%, P = 0.02). No local recurrences occurred during a median (interquartile range) follow‐up of 15.2 (7–27.2) and 18.1 (8.2–30.9) months in the RAPN and OPN groups, respectively. There was no difference in estimated glomerular filtration rate preservation rates between groups for the early (P = 0.26) and latest (P = 0.22) functional follow‐up. Conclusion For completely endophytic renal tumours, both OPN and RAPN have excellent outcomes when performed by experienced surgeons at a high‐volume centre. For skilled robotic surgeons, RAPN is a safe and effective alternative to OPN with the advantages of shorter length of stay and less blood loss.
      PubDate: 2016-08-01T00:10:41.645792-05:
      DOI: 10.1111/bju.13572
  • Evolution of the Robotic Orthotopic Ileal Neobladder Formation: A Step by
           Step Update to The USC Technique
    • Authors: Sameer Chopra; Andre Luis de Castro Abreu, Andre K. Berger, Shuchi Sehgal, Inderbir Gill, Monish Aron, Mihir M. Desai
      Abstract: Objective To describe, step‐by‐step, our updated, time‐efficient technique for intracorporeal neobladder formation. Patients and Methods There are five main surgical steps to forming the intracorporeal orthotopic ileal neobladder: isolation of the small bowel intestine; small bowel anastomosis; bowel detubularization and suture of the posterior wall of the neobladder; neobladder‐urethral anastomosis and folding the pouch; and ureteral‐chimney anastomosis. Improvements have been made during these steps to improve time efficiency without compromising neobladder formation. Results A total of 65 cm of small intestinal bowel is removed for neobladder formation. Our technical improvements have demonstrated an improvement in operative time from 450 minutes to 360 minutes. Conclusion We describe an updated step‐by‐step technique to our institution's robotic intracorporeal orthotopic ileal neobladder formation using a time‐efficient technique. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-30T09:10:30.423817-05:
      DOI: 10.1111/bju.13611
  • Preliminary experience using a tunica vaginalis flap as the dorsal
           component of Bracka's urethroplasty
    • Authors: L. Harper; JL Michel, F Sauvat
      Abstract: Purpose To evaluate clinical use of tunica vaginalis flap as the dorsal component of a two‐stage urethroplasty in boys with cripple hypospadias. Patients and Method We performed the first stage of a Bracka two‐stage urethroplasty, using a tunica vaginalis flap as the dorsal component in 6 boys with cripple hypospadias. We analyzed their clinical characteristics and the results of this technique. Results The average age of the patients was 4 years and 9 months (range: 34‐120 months). The average number of previous procedures the children had undergone was 4 (range: 3‐5). At 6 months follow‐up, all children presented significant fibrosis of the dorsal graft rendering it unusable for tubularization. Conclusions Exposure to the external environment seems to induce retraction and fibrosis of the tunica vaginalis. We believe one should be very cautious about using tunica vaginalis as the dorsal component of a two‐stage urethroplasty, as significant fibrosis might well render the flap unusable. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-26T09:15:27.77803-05:0
      DOI: 10.1111/bju.13604
  • Accuracy of ultrasound for renal stone detection and size determination:
           is it good enough for management decisions?
    • Authors: V Ganesan; S De, D Greene, FCM Torricelli, M Monga
      Abstract: Objectives To determine the sensitivity and specificity of ultrasound (US) for detecting renal calculi and to assess the accuracy of US for determining size of calculi and how this can affect counselling decisions. Materials and methods We retrospectively identified all patients at our institution with a diagnosis of nephrolithiasis who had an US followed by a non‐contrast computed tomographic (CT) within 60‐days. Patient characteristics, stone size (maximum axial diameter), and stone location was collected. Sensitivity, specificity, and size accuracy of ultrasound was determined using CT as the standard. Results A total of 552 US and CT examinations met the inclusion criteria. Overall the sensitivity and specificity of US was 54% and 91% respectively. There was a significant association between sensitivity of US and stone size (p < 0.001) but not with stone location (p = 0.58). US significantly overestimated the size of stones in the 0‐10 mm range (p < 0.001). Assuming stones 0 mm – 4 mm will be observed and stones ≥5 mm could be counselled on the alternative of intervention, we found that in 14% (54/384) of cases where CT would suggest observation, US would recommend an intervention. On the other hand, when using CT would suggest an intervention, US would suggest observation in 39% (65/168) of cases. On average 22% (119/552) of patients could be inappropriately counselled. Stones classified as 5‐10 mm by US had the highest probability, 43% (41/96), of having recommendation changed when a CT was performed. The use of KUB and US increases sensitivity (78%) but still 37% (13/35) of patients may inappropriately be counselled to undergo observation. Conclusions Using US to guide clinical decision making for residual or asymptomatic calculi is limited by low sensitivity and inability to accurately size the stone. As a result, 1 in 5 patients may be inappropriately counselled when using US alone. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-26T09:10:27.045077-05:
      DOI: 10.1111/bju.13605
  • Active surveillance is suitable for intermediate term follow‐up of renal
           oncocytoma diagnosed by percutaneous core biopsy
    • Authors: Shuo Liu; Stephen Lee, Prem Rashid, Haider Bangash, Akhlil Hamid, Jason Lau, Ronald Cohen
      Abstract: Objectives To evaluate the intermediate outcome of conservative management in patients with biopsy‐proven oncocytoma. Patients and Methods Patients with oncocytoma diagnosed on percutaneous core biopsy between January 2000 to December 2014 were identified from the renal biopsy database of a large specialist urologic pathology laboratory. After review of patient clinical records, the study cohort comprised only of patients enrolled in active surveillance. Clinicopathological and follow‐up details were reviewed for each case, in particular: type and interval of surveillance imaging, tumour growth, definitive intervention and reason for intervention. Where possible, correlation was made between the final surgical and the initial biopsy specimens. Results Fifty three patients diagnosed with oncocytoma on core biopsy were initially placed on active surveillance with median follow‐up of 34 months (range 6–109). The median age at diagnosis was 65 years (range 20–85) and median tumour size was 30 mm (range 13–87). Mean average tumour growth was 1.4 mm per annum (median 0 mm/year) with the majority (36 of 53, 68%) exhibiting minimal growth (less than 2 mm per annum) or partial regression. Forty seven of the 53 patients remained on active surveillance with no significant progression. Six patients elected to undergo definitive intervention (five surgical excision, one ablation). Renal oncocytoma was confirmed in all five patients who underwent surgical excision of their lesions. Conclusions The majority of oncocytomas in this study showed minimal growth rate or regression. Patients with biopsy proven oncocytoma can be conservatively managed with active surveillance.
      PubDate: 2016-07-26T01:22:04.519225-05:
      DOI: 10.1111/bju.13538
  • The Impact Of United States Preventive Services Task Force (USPTSTF)
           Recommendations Against PSA Testing On PSA Testing In Australia
    • Authors: Homayoun Zargar; Roderick den Bergh, Daniel Moon, Nathan Lawrentschuk, Anthony Costello, Declan Murphy
      Abstract: Objective To assess the impact of USPTSTF recommendations on PSA testing, prostate biopsy and prostatectomy in Australian men based on the available Medicare data. Patients and Methods Events were identified using Medicare item numbers for PSA (66655,66659), prostate biopsy (37219), prostatectomy (37210) and prostatectomy with lymph node dissection (37211) The occurrences of each procedure was queried per 100 000 capita for consecutive financial years over the period 2000‐2015. For each item number reports were also generated for all Australian states. For PSA testing the data was stratified for the three age groups of 45‐54, 55‐64 and 65‐74 years old. For assessment of the rate of prostatectomy the capita rate values for two item numbers of prostatectomy (37210) and prostatectomy with lymph node dissection (37211) were summed up. Results Steady declines in per capita incidences of all five item numbers assessed were observed for the three consecutive financial years (2013‐2015) since the publication of USPTSTF recommendation statement. These declines were observed across all Australian states. When examining the rate of PSA testing for the three age brackets 45‐54, 55‐64 and 65‐74 years old similar trends were identified Conclusions Since the introduction of USPTSTF recommendation statement there has been a steady nationwide decline in per capita incidences of PSA testing, prostate biopsy and prostatectomy based on the Australian Medicare data. Whether these declines are in the right direction toward reduction in over diagnosis and over treatment of clinically insignificant prostate cancer or stage migration toward more locally advanced disease due to lost opportunity in diagnosing and treating early clinically significant prostate cancer will remain to be seen. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-25T11:30:35.752465-05:
      DOI: 10.1111/bju.13602
  • The potential role of unregulated autonomous bladder micromotions in
           urinary storage and voiding dysfunction; overactive bladder and detrusor
    • Authors: M.J. Drake; A. Kanai, D.A. Bijos, Y. Ikeda, I. Zabbarova, B. Vahabi, C.H. Fry
      Abstract: The isolated bladder shows autonomous micromotions, which increase with bladder distension, generate sensory nerve activity, and are altered in models of urinary dysfunction. Intravesical pressure resulting from autonomous activity putatively reflects three key variables; the extent of micromotion initiation, distances over which micromotions propagate, and overall bladder tone. In vivo, these variables are subordinate to the efferent drive of the central nervous system. In the micturition cycle storage phase, efferent inhibition keeps autonomous activity generally at a low level, where it may signal “state of fullness” while maintaining compliance. In the voiding phase, mass efferent excitation elicits generalized contraction (global motility initiation). In lower urinary tract dysfunction, efferent control of the bladder can be impaired, for example due to peripheral “patchy” denervation. In this case, loss of efferent inhibition may enable unregulated micromotility, and afferent stimulation, predisposing to urinary urgency. If denervation is relatively slight, the detrimental impact on voiding may be low, as the adjacent innervated areas may be able to initiate micromotility synchronous with the efferent nerve drive, so that even denervated areas can contribute to the voiding contraction. This would become increasingly inefficient the more severe the denervation, such that ability of triggered micromotility to propagate sufficiently to engage the denervated areas in voiding declines, so the voiding contraction increasingly develops the characteristics of underactivity. In summary, reduced peripheral coverage by the dual efferent innervation (inhibitory and excitatory) impairs regulation of micromotility initiation and propagation, potentially allowing emergence of overactive bladder and, with progression, detrusor underactivity. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-22T07:15:22.320644-05:
      DOI: 10.1111/bju.13598
  • Comparative testing of reliability and audit utility of ordinal objective
           calculus complexity scores. Can we make an informed choice yet'
    • Authors: Jiten Jaipuria; Manav Suryavanshi, Tridib K. Sen
      Abstract: Objectives To assess reliability of Guy's, Seoul National University renal stone (S‐RESC) and S.T.O.N.E. scores in percutaneous nephrolithotomy (PCNL) and assess utility in discriminating outcomes [Stone free rate (SFR), complications, need for multiple PCNL sessions and auxiliary procedures] valid across parameters of experience of surgeon, independence from surgical approach, and variations in institution‐specific instrumentation. Patients and methods Prospectively maintained database of 2 tertiary institutions was analysed (606 cases). Institutes differed in instrumentation while overall surgical team comprised – two trainees (experience 1000 cases). Scores were assigned and reassigned after 4 months by one trainee and expert surgeon. Interrater and test‐retest agreement were analysed by Cohen's kappa and Intraclass correlation coefficient. Multivariate logistic regression models were created adjusting outcomes for the institution, comorbidity, amplatz size, access tract location, the number of punctures, the experience level of the surgeon, and individual scoring system, and receiver operating curves were analysed for comparison. Results Despite some areas of inconsistencies, individually all scores had excellent interrater and test‐retest concordance. On multivariable analyses while the experience of the surgeon and surgical approach characteristics (such as access tract location, amplatz size, and number of punctures) remained independently associated with different outcomes in varying combinations, calculus complexity scores were found consistently independently associated with all outcomes. S‐RESC score had a superior association with SFR, the need for multiple PCNL sessions and auxiliary procedures. Conclusion Individually all scoring systems performed well. On cross comparison, S‐RESC score consistently emerged more superiorly associated with all outcomes signifying the importance of the distributional complexity of calculus (which also indirectly amalgamates influence of stone number, size, and anatomic location) in discriminating outcomes. Our study proves the utility of scores in prognosticating multiple outcomes and also clarifies important aspects of their practical application including future roles such as benchmarking, audit, training and objective assessment of surgical technique modifications. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-22T06:55:43.623573-05:
      DOI: 10.1111/bju.13597
  • Randomized controlled study of the efficacy and safety of continuous
           saline bladder irrigation after transurethral resection for the treatment
           of non‐muscle invasive bladder cancer
    • Authors: Takehisa Onishi; Yusuke Sugino, Takuji Shibahara, Satoru Masui, Tadashi Yabana, Takeshi Sasaki
      Abstract: Objective To evaluate the efficacy and safety of continuous saline bladder irrigation (CSBI) after transurethral resection of bladder tumor (TURBT) in patients with low‐ to intermediate‐risk non‐muscle invasive bladder cancer (NMIBC). Patients and methods In this prospective randomized study, 250 patients with primary low‐to intermediate‐risk tumors were enrolled. Patients were randomly allocated to receive CSBI (2,000 ml/h for first 1 hour, then 1,000 ml/h for 2 hours, and then 500 ml/h for 15 hours) or a single immediate instillation of mitomycin C (MMC) after TURBT. Primary end point was recurrence‐free survival, and secondary end points were progression‐free survival and adverse events. Results A total of 227 patients (114 in CSBI group and 113 in MMC group) remained for analysis after exclusion. The median follow‐up period was 37 months. No significant differences for patients’ characteristics were observed between the groups. Five‐year recurrence‐free rates for CSBI and MMC were 62.6% (95% confidence interval [CI]: 0.49‐0.73) and 70.4% (95% CI: 0.59‐0.78), respectively. Kaplan‐Meire analysis of recurrence‐free survival did not show any significant differences between the groups (log rank test: P = 0.53). Furthermore, there were no significant differences between the groups in terms of tumor progression rate and the median time to first recurrence. The incidence of adverse events was significantly lower in CSBI group. Conclusions CSBI after TURBT may be a treatment option for patients with low‐ to intermediate –risk NMIBC in terms of its prophylactic effect and safety. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-22T06:55:33.361119-05:
      DOI: 10.1111/bju.13599
  • The use of portable video media (PVM) versus standard verbal communication
           (SVC) in the urological consent process: a multicentre, randomised
           controlled, crossover trial
    • Abstract: Background Informed consent is a crucial component of patient care. Portable video media is an emerging technology which may help improve the consent process. Objectives To determine if portable video media (PVM) improves patient's knowledge and satisfaction acquired during the consent process for cystoscopy and insertion of a ureteric stent compared to standard verbal communication (SVC). Design, Participants and Methods Multi‐centre randomised controlled crossover trial. Patients requiring cystoscopy and stent insertion were recruited from two major teaching hospitals in Australia over a 15‐month period (July 2014 – December 2015). Information delivery via PVM and SVC. PVM consisted of an audio‐visual presentation with cartoon animation presented on an iPad. Patient satisfaction was assessed using the validated Client Satisfaction Questionnaire‐8 (max score 32) and knowledge was tested using a true/false questionnaire (max score 28). Questionnaires were tested after first intervention and after crossover. Scores were analysed using independent samples t‐test and Wilcoxon signed‐rank test for crossover analysis. Results Eighty‐eight patients were recruited. A significant 3·1 point (15·5%) increase in understanding was demonstrable favouring the use of PVM (p
      PubDate: 2016-07-21T02:31:50.693417-05:
      DOI: 10.1111/bju.13595
  • The ProCare Trial: a phase II randomised controlled trial of shared care
           for follow‐up of men with prostate cancer
    • Authors: Jon D Emery; Michael Jefford, Madeleine King, Dickon Hayne, Andrew Martin, Juanita Doorey, Amelia Hyatt, Emily Habgood, Tee Lim, Cynthia Hawks, Marie Pirotta, Lyndal Trevena, Penelope Schofield
      Abstract: Objectives To test the feasibility and efficacy of a multifaceted model of shared care for men after completion of treatment for prostate cancer. Patients and Methods Men who had completed treatment for low to moderate risk prostate cancer within the previous eight weeks were eligible. Participants were randomised to usual care or shared care. Shared care entailed substituting two hospital visits with three visits in primary care, a survivorship care plan, recall and reminders, and screening for distress and unmet needs. Outcome measures included psychological distress, prostate cancer‐specific quality of life (PCSQoL), satisfaction and preferences for care and health care resource use. Results 88 men were randomised (Shared Care n=45; Usual Care n=43). There were no clinically important or statistically significant differences between groups on distress, PCSQoL, or satisfaction with care. At the end of the trial men in the intervention group were significantly more likely to prefer a shared care model to hospital follow‐up than those in the control group Intervention 63% vs Control 24% p=0.0007). There was high compliance with PSA monitoring in both groups. The shared care model was cheaper than usual care (Shared care AUS$1,411; Usual Care AUS$1,728; difference AUS$323 (plausible range AUS$91‐554)). Conclusion Well‐structured shared care for men with low to moderate risk prostate cancer is feasible and appears to produce clinically comparable outcomes to standard care at lower cost. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-19T01:35:29.712123-05:
      DOI: 10.1111/bju.13593
  • Routinely reported ‘equivocal’ lymphovascular invasion in
           prostatectomy specimens is associated with adverse outcomes
    • Authors: Elena Galiabovitch; Christopher M. Hovens, Justin S. Peters, Anthony J. Costello, Shane Battye, Sam Norden, Andrew Ryan, Niall M. Corcoran
      Abstract: Objective To evaluate the significance of routinely reported ‘equivocal’ lymphovascular invasion in prostatectomy specimens of patients with clinically localised prostate cancer. Materials and Methods Prospectively collected data from men who underwent prostatectomy for clinically localised prostate cancer were retrospectively reviewed. Rates of adverse pathological features and biochemical recurrence were compared between tumours positive, negative or ‘equivocal’ for lymphovascular invasion. Multivariable Cox regression analysis was performed to identify independent predictors of biochemical recurrence. Results In 1310 consecutive cases, lymphovascular invasion was present definitively in 82 (6.3%) and equivocally in 43 (3.3%). Similar to definitive lymphovascular invasion, ‘equivocal’ lymphovascular invasion was significantly associated with other adverse pathological features, including advanced stage, higher Gleason grade, and surgical margin positivity. Biochemical recurrence occurred more frequently in patients with tumours ‘equivocal’ (61%) or positive for lymphovascular invasion (71%) than in negative patients (14.7%). In addition, patients with both definitive and equivocal lymphovascular invasion had a significantly shorter biochemical recurrence‐free survival compared to negative patients. Multivariable Cox regression analysis indicated that the presence of either definitive or ‘equivocal’ lymphovascular invasion were independent predictors of disease recurrence (HR 3.32, 95%CIs 2.3‐4.8, p
      PubDate: 2016-07-19T01:35:27.28618-05:0
      DOI: 10.1111/bju.13594
  • Comparison of spinal cord contusion and transection: functional and
           histological changes in the rat urinary bladder
    • Authors: Benjamin N. Breyer; Thomas M. Fandel, Amjad Alwaal, E. Charles Osterberg, Alan W. Shindel, Guiting Lin, Emil A. Tanagho, Tom F. Lue
      Abstract: Objective To compare the effect of complete transection (tSCI) and contusion injury (cSCI) on bladder function and bladder wall structure in rats. Materials and Methods 30 female Sprague‐Dawley rats were randomly divided into three equal groups: uninjured controls, cSCI, and tSCI. The cSCI group underwent spinal cord contusion, while the tSCI group underwent complete spinal cord transection. 24‐hour metabolic cage measurement and conscious cystometry were performed at 6 weeks post‐injury. Results Conscious cystometry analysis showed that cSCI and tSCI groups had significantly larger bladder capacities than the control group. The cSCI group had significantly more non‐voiding detrusor contractions than the tSCI group. Both injury groups displayed more non‐voiding contractions compared to the control group. Mean threshold pressure was significantly higher in the tSCI group than in control and cSCI groups. The number of voids in the tSCI group was less compared to the control group. Metabolic cage analysis showed that the tSCI group had larger maximum voiding volume as compared to control and cSCI. VAChT/smooth muscle immunoreactivity was higher in control than in cSCI or tSCI rats. The area of calcitonin gene‐related peptide (CGRP) staining was lower in tSCI as compared to control or cSCI. Conclusions Spinal cord transection and contusion produce different bladder phenotypes in rat models of SCI. Functional data suggest that the tSCI group has obstructive high‐pressure voiding pattern, while the cSCI group has more uninhibited detrusor contractions. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-19T01:31:07.895521-05:
      DOI: 10.1111/bju.13591
  • ICUD‐EAU International Consultation on Minimally Invasive Surgery in
           Urology: Laparoscopic and Robotic Adrenalectomy
    • Authors: Mark W. Ball; Ashok K. Hemal, Mohamad E. Allaf
      Abstract: Objective To provide an evidence‐based systematic review of the use of laparoscopic and robotic adrenalectomy in the treatment of adrenal disease as part of the International Consultation on Urologic Diseases and European Association of Urology consultation on Minimally Invasive Surgery in Urology. Methods A systematic literature search (January 204‐January 2014) was conducted to identify comparative studies assessing the safety and efficacy of minimally invasive adrenal surgery. Subtopics including the role of minimally invasive surgery for pheochromocytoma, adrenocortical carcinoma, and large adrenal tumors were examined. Additionally, the role of transperitoneal and retroperitoneal approaches, as well as laparoendoscopic single‐site (LESS) and robotic adrenalectomy were reviewed. Result The major findings are presented in an evidence‐based fashion. Large retrospective and prospective data were analyzed. A set of recommendations provided by the committee was produced. Conclusions Laparoscopic surgery should be considered first line therapy for benign adrenal masses requiring surgical resection. Laparoscopic surgery should be considered first line therapy for patients with pheochromocytoma. While a laparoscopic approach may be feasible for select cases of ACC without adjacent organ involvement, an open surgical approach remains the gold standard. Large adrenal tumors without preoperative or intraoperative concern for ACC may be safely resected via a laparoscopic approach. Both transperitoneal and retroperitoneal approaches to laparoscopic adrenalectomy is safe. The approach should be chosen based on surgeon training and experience. LESS adrenalectomy should be considered an an alternative to laparoscopic adrenalectomy but requires further study. Robotic adrenalectomy may be considered an alternative to laparoscopic adrenalectomy but requires further study . This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-19T01:31:01.933677-05:
      DOI: 10.1111/bju.13592
  • Liquid biopsy: ready to guide therapy in advanced prostate cancer?
    • Abstract: The identification of molecular markers associated with response to specific therapy is a key step for the implementation of personalized treatment strategies in patients with metastatic prostate cancer (PC). Only in a low proportion of patients, biopsies of metastatic tissue are performed. Circulating tumor cells (CTC), cell free‐DNA (cfDNA) and RNA offer the potential for non‐invasive characterization of disease and molecular stratification of patients. Furthermore, a “liquid biopsy” approach permits longitudinal assessments, allowing sequential monitoring of response and progression and the potential to alter therapy based on observed molecular changes. In PC, CTC enumeration using the CellSearch© platform correlates with survival. Recent studies on the presence of androgen receptor variants in CTC have shown that the such molecular characterization of CTC provides a potential for identifying patients with resistance to agents that inhibit the androgen signaling axis, such as abiraterone and enzalutamide. New developments in CTC isolation, as well as in‐vitro and in‐vivo analysis of CTC will further promote the use of CTC as a tool for retrieving molecular information from advanced tumors in order to identify mechanisms of therapy resistance. In addition to CTC, nucleic acids such as RNA and cell free DNA (cfDNA) released by tumor cells into the peripheral blood contains important information on transcriptomic and genomic alterations in the tumors. Initial studies have shown that genomic alterations of the androgen receptor and other genes detected in CTC or cfDNA of patients with castration resistant prostate cancer (CRPC) correlate with treatment outcomes to enzalutamide and abiraterone. Due to recent developments in high throughput analysis techniques, it is likely that CTC, cfDNA and RNA will be an important component of personalized treatment strategies in the future. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-19T01:25:58.470194-05:
      DOI: 10.1111/bju.13586
  • Raised pre‐operative INR identifies patients at high risk of
           peri‐operative death after simultaneous renal and cardiac surgery for
           tumours involving the peri‐diaphragmatic inferior vena cava (IVC) and
           right atrium
    • Authors: Tim O'Brien; Archie Fernando, Kay Thomas, Mieke Van Hemelrijck, Craig Bailey, Conal Austin
      Abstract: Background The ability to predict and therefore avoid surgery in those patients likely to die from simultaneous renal and cardiac surgery for urological tumours involving the peri‐diaphragmatic vena cava and right atrium would be valuable. Objective To identify pre‐operative factors that predict thirty‐day mortality (TDM) in patients undergoing this type of surgery. Design setting and participants Retrospective review of peri‐operative outcomes in patients managed between December 2007 and January 2016 by a single team. Outcome measurements and statistical analysis Relationships with outcome analysed using Fisher's Exact and Mann Whitney U tests. Results and Limitations 46 patients of whom 41/46 (89%) underwent surgery. 20 males; 21 females. Median age 65 yrs (range 17‐95). 37 renal cell cancer, 1 adrenal cancer, 2 primitive neuroectodermal tumours and 1 leiomyosarcoma. Overall TDM 3/41 patients (7%). INR, age and eGFR correlated significantly with TDM. Mortality if INR >1.5, 3/5 (60%) compared to 0/36 (0%) if INR 1.5 and age >70 years 3/3 (100%) INR correlated with serious complications (≥Clavien 3) (INR>1.5: 5/5 (100%) vs INR
      PubDate: 2016-07-19T01:25:44.444591-05:
      DOI: 10.1111/bju.13587
  • Nanotechnology combination therapy: Tyrosine kinase‐bound gold nanorod
           and laser thermal ablation produce a synergistic higher treatment response
           of renal cell carcinoma in animal model
    • Abstract: Objective To investigate tyrosine kinase inhibitors (TKI) and gold nanorod (AuNR) paired with photothermal ablation in a human metastatic clear cell renal cell carcinoma mouse model. Nanoparticles have been successful as platform for targeted drug delivery in the treatment of urologic cancers. Likewise, the use of nanoparticles in photothermal tumor ablation, though early in its development, has provided promising results. Our previous in vitro studies of nanoparticles loaded with both TKI and gold nanorods and activated with photothermal ablation have demonstrated significant synergistic cell kill greater than each individual arm alone. This study is a translation of our initial findings to an in vivo model. Materials and Methods Immunologically naïve nude mice (Athymic Nude‐Foxn1nu) were injected bilaterally on the flanks (n=36) with 2.5 x 106 cells of a human metastatic renal cell carcinoma cell line (RCC 786‐O). Subcutaneous xenograft tumors developed 1 cm palpable nodules. Gold Nanorods encapsulated in Human Serum Albumin Protein nanoparticles were synthesized with or without a TKI and injected directly into the tumor nodule. Irradiation was administered with an 808 nm LED diode laser for six minutes. Animals were sacrificed 14 days post‐irradiation; tumors were excised, formalin fixed, paraffin embedded, and evaluated for size and percent necrosis by a GU pathologist. Untreated contralateral flank tumors were used as controls. Results In mice that did not receive irradiation, TKI alone yielded 4.2% tumor necrosis on the injected side and administration of HSA‐AuNR‐TKI alone yielded 11.1% necrosis. In laser ablation models, laser ablation alone yielded 62% necrosis and when paired with HSA‐AuNR had 63.4% necrosis. The combination of laser irradiation and HSA‐AuNR‐TKI had cell kill of 100%. Conclusions In the absence of laser irradiation, TKI treatment alone or when delivered via nanoparticle produced moderate necrosis. Irradiation with and without gold particles alone also improves tumor necrosis. However, when irradiation is paired with gold particle and drug‐loaded nanoparticle, the combination therapy demonstrated the most significant and synergistic complete tumor necrosis of 100% (p
      PubDate: 2016-07-19T01:25:43.255177-05:
      DOI: 10.1111/bju.13590
  • A 22‐year Restrospective Study: Educational Update and New Referral
           Pattern of Age at Orchidopexy
    • Abstract: Objectives Research suggesting progressive deterioration in an undescended testis (UDT) has led to the reduction in the target age for orchidopexy to 6‐12 months of age. However, it is still unknown whether changing targets have altered practice. The objective was to determine the current age at orchidopexy in China and whether changing targets have altered practice. Materials and Methods The demographics of orchidopexies performed in Children's Hospital of Chongqing Medical University between 1993 and 2014 were reviewed. Survey of general publics’ cognition of undescended testes and survey of primary healthcare practitioners’ current opinion on age at orchidopexy and referral patterns were performed. Results A total of 3784 orchidopexies were performed over 22 years. The median age at orchidopexy fell between 1993 to 2014. There was an initial drop in the age for orchidopexy between 2000‐2010(3 years old)compared with the median age between 1993‐2000(4 years old).(P
      PubDate: 2016-07-19T01:25:35.090771-05:
      DOI: 10.1111/bju.13588
  • Validation of VEGFR1 rs9582036 as predictive biomarker in metastatic
           clear‐cell renal cell carcinoma patients treated with sunitinib
    • Abstract: Objectives To validate vascular endothelial growth factor receptor‐1 (VEGFR1) single nucleotide polymorphism (SNP) rs9582036 as a potential predictive biomarker in metastatic clear‐cell renal cell carcinoma (m‐ccRCC) patients treated with sunitinib. Materials and methods m‐ccRCC patients receiving sunitinib as first‐line targeted therapy were included. We assessed response rate (RR), progression‐free survival (PFS), overall survival (OS), and clinical and biochemical parameters associated with outcome. We genotyped five VEGFR1 SNPs: rs9582036, rs7993418, rs9554320, rs9554316 and rs9513070. Association with outcome was studied by univariate analysis and by multivariate Cox regression. Additionally, we updated survival data of our discovery cohort as described previously. Results Sixty‐nine patients were included in the validation cohort. rs9582036 CC‐carriers had a poorer PFS (8 versus 12 months, p=0.02) and OS (11 versus 27 months, p=0.003) compared to AC/AA‐carriers. rs7993418 CC‐carriers had a poorer OS (8 versus 24 months, p=0.004) compared to TC/TT‐carriers. rs9554320 AA‐carriers had a poorer RR (0% versus 53%, p=0.009), PFS (5 versus 12 months, p=0.003) and OS (10 versus 25 months, p=0.004) compared to AC/CC‐carriers. When pooling patients from the discovery cohort, as described previously (n=88), and the validation cohort, in the total series of 157 patients, rs9582036 CC‐carriers had a poorer RR (8% versus 49%, p=0.004), PFS (8 versus 14 months, p=0.003) and OS (13 versus 30 months, p=0.0004) compared to AC/AA‐carriers. Unfavorable prognostic markers at start of sunitinib were well balanced between rs9582036 CC‐ and AC/AA‐carriers. Conclusion VEGFR1 rs9582036 is a candidate predictive biomarker in m‐ccRCC‐patients treated with sunitinib. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-15T03:15:30.284154-05:
      DOI: 10.1111/bju.13585
  • Patient‐reported outcomes in the ProtecT randomised trial of clinically
           localised prostate cancer treatments: design and baseline urinary, bowel
           and sexual function and quality of life
    • Authors: JA Lane; C Metcalfe, GJ Young, TJ Peters, J Blazeby, KNL Avery, D Dedman, L Down, MD Mason, DE Neal, FC Hamdy, JL Donovan,
      Abstract: Objectives To present the baseline patient‐reported outcome measures (PROMs) in the ProtecT (Prostate testing for cancer and Treatment) randomised trial comparing active monitoring, radical prostatectomy and external‐beam conformal radiotherapy for localised prostate cancer and to compare results with other populations. Materials and methods 1,643 randomised men aged 50‐69 years in nine UK cities diagnosed with clinically localised disease identified by prostate‐specific antigen (PSA) testing (1999‐2009). Validated PROMs for disease‐specific (urinary, bowel and sexual function) and condition‐specific quality of life impacts (EPIC: 2005 onwards, ICIQ‐UI: 2001 onwards, ICSmaleSF), anxiety and depression (HADS), generic mental and physical health (SF‐12, EQ‐5D‐3L) were completed at prostate biopsy clinics before randomisation. Descriptive statistics presented by treatment allocation and by men's age and at biopsy and PSA testing time points for selected measures. Results 1,438 participants completed biopsy questionnaires (88%) and between 77‐88% were analysed for individual PROMs. Fewer than 1% of participants were using pads daily (5/754). Storage lower urinary tract symptoms (LUTS) were frequent (e.g. nocturia 22%, 312/1423). Bowel symptoms were rare, except for loose stools (16%, 118/754). One third of participants reported erectile dysfunction (241/735) and for 16% (118/731) this was a moderate or large problem. Depression was infrequent (80/1399, 6%) but 20% of participants (278/1403) reported anxiety. Sexual function and bother were markedly worse in older men (65‐70 years), whilst urinary bother and physical health was somewhat worse than in younger men (49‐54 years, all p
      PubDate: 2016-07-14T09:35:30.688114-05:
      DOI: 10.1111/bju.13582
  • Robotic perineal radical prostatectomy and pelvic lymph node dissection
           using a purpose‐built single‐port robotic platform
    • Authors: Daniel Ramirez; Matthew J. Maurice, Jihad H. Kaouk
      Abstract: Objective To describe the features of the novel, purpose‐built da Vinci model SP1098 single‐port (SP) robotic platform and describe a step‐by‐step approach for perineal prostatectomy and pelvic lymph node dissection in a cadaver model. Methods 3 SP robotic radical perineal prostatectomies and 2 pelvic lymph node dissections were performed on 3 male cadavers in order to assess the feasibility of the SP1098 da Vinci robotic platform. The steps of the procedure included division of the rectourethralis muscle, splitting of the levator ani muscles bilaterally, opening of Denonvilliers fascia with dissection of the seminal vesicles, apical dissection and urethral division, anterior and lateral dissection with ligation of prostatic pedicles, bilateral pelvic lymph node dissection, and creation of the new vesicourethral anastomosis. The main outcomes assessed were operative time per step, total operative time, intraoperative complications and need for conversion to conventional or open techniques. Results No conversions were required. No intraoperative complications were seen. Median OR time for performing SP robotic radical perineal prostatectomy and pelvic lymph node dissection was 210 minutes (range 180‐240). Conclusions We demonstrate the feasibility and efficacy of a novel, purpose‐built robotic system in performing SP radical perineal prostatectomy and, for the first time, describe feasibility of robotic perineal lymph node dissection. This SP system will facilitate single port applications and allow surgeons to perform major urologic operations via a small, single incision while preserving triangulation and optics, and eliminating clashing between instruments. Future clinical studies are needed to support these encouraging outcomes. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-13T11:21:55.741357-05:
      DOI: 10.1111/bju.13581
  • Predicting Complications in Partial Nephrectomy for T1a Tumors: Does
           Approach Matter?
    • Authors: Daniel Ramirez; Matthew J. Maurice, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, Jihad H. Kaouk
      Abstract: Objectives Contemporary guidelines for treatment of localized renal masses suggest nephron‐sparing surgery (NSS) as an option for T1a tumors in appropriate patients. Large comparative series assessing the risk of complications between open and robotic approaches for partial nephrectomy are lacking. Our objective is to assess differences in complications following robotic (RPN) and open partial nephrectomy (OPN) among experienced surgeons. Patients and methods We identified patients in our IRB‐approved, prospectively maintained database who underwent OPN or RPN for management of unifocal, T1a renal tumors at our institution between January 2011 and August 2015. Our primary outcome measure was the rate of 30‐day overall postoperative complications. Baseline patient factors, tumor characteristics and perioperative factors, including approach, were evaluated to assess the risk of complication. Results Patients who underwent OPN were found to have a higher rate of overall complications (30.3% vs 18.2%, p=0.038) with wound complications accounting for the majority of these events (11.8% vs 1.8%, p
      PubDate: 2016-07-13T11:20:44.439266-05:
      DOI: 10.1111/bju.13583
  • Germline Genetic Variation in JAK2 as a Prognostic Marker in Castration
           Resistant Prostate Cancer
    • Authors: Ben Y. Zhang; Shaun M. Riska, Douglas W. Mahoney, Brian A. Costello, Rhea Kohli, J.F. Quevedo, James R. Cerhan, Manish Kohli
      Abstract: Objectives To evaluate the prognostic significance of germline variation in candidate genes in patients with castration‐resistant prostate cancer (CRPC). Methods Germline DNA was extracted from peripheral blood mononuclear cells of CRPC patients enrolled in a clinically annotated registry. Fourteen candidate genes implicated in either initiation or progression of prostate cancer were tagged using single nucleotide polymorphisms (SNPs) from HapMap with minor allele frequency of >5%. The primary endpoint was overall survival (OS), defined as time from development of CRPC to death. Principal component analysis was used for gene levels tests of significance. For SNP level results the per allele hazard ratios (HR) and 95% confidence intervals (CI) under the additive allele model were estimated using Cox regression adjusted for age at CRPC and Gleason score (GS). Results Two hundred and forty two CRPC patients were genotyped (14 genes; 84 SNPs). The median age of the cohort was 69 years (range 43‐93). The GS distribution was 55% with GS≥8, 32% with GS=7 and 13% with GS
      PubDate: 2016-07-13T11:20:34.961192-05:
      DOI: 10.1111/bju.13584
  • Impact of ischemia time on renal function after partial nephrectomy: a
           systematic review
    • Abstract: Objective To assess the impact of ischemia on renal function after partial nephrectomy. Materials and methods A literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) criteria. In January 2015, the Medline and Embase databases were systematically searched using the protocol (“warm ischemia”[mesh] OR “warm ischemia”[ti]) AND (“nephrectomy”[mesh] OR “partial nephrectomy”[ti]). An updated search was performed in December 2015. Only studies based on a solitary kidney model or on a two‐kidney model but with assessment of split renal function were included in this review. Results Of the 1119 studies identified, 969 abstracts were screened after duplicates were removed: 29 articles were finally included in this review, including 9 studies that focused on patients with a solitary kidney. None of the nine studies adjusting for the amount of preserved parenchyma found a negative impact of warm ischemia time on postoperative renal function, unless this was extended beyond a 25‐minute threshold. The quality and the quantity of preserved parenchyma appeared to be the main contributors to postoperative renal function. Conclusion Currently, no evidence supports that limited ischemia time (i.e. ≤25 min) has a higher risk of reducing renal function after PN compared to a “zero ischemia” technique. Several recent studies have suggested that prolonged warm ischemia (>25–30 min) could cause an irreversible ischemic insult to the surgically treated kidney. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-13T11:20:34.302067-05:
      DOI: 10.1111/bju.13580
  • Urethral diverticulectomy with Martius fat pad interposition improves
           symptom resolution and reduces recurrence
    • Authors: S Malde; N Sihra, S Naaseri, M Spilotros, E Solomon, M Pakzad, R Hamid, JL Ockrim, TJ Greenwell
      Abstract: Objective To assess the presenting features and medium‐term symptomatic outcomes in women having excision of urethral diverticulum with Martius fat pad interposition Patients and Methods We reviewed our prospective database of all female patients having excision of a symptomatic urethral diverticulum between 2007 and 2015. Data on demographics, presenting symptoms and clinical features were collected, as well as post‐operative outcomes. Results Seventy women with a mean age of 46.5 years (range 24‐77) underwent excision of urethral diverticulum with Martius fat pad interposition over this period. The commonest presenting symptoms were a urethral mass (69%), urethral pain (61%) and dysuria (57%). Pre‐existing SUI was present in 41% (29) of women. Following surgery at a mean 18.9 (SD 16.4) months follow‐up (median 14 months), complete excision of urethral diverticulum was achieved in 100%, with resolution of urethral mass, dysuria and dyspareunia in all patients, and urethral pain in 81%. Immediately following surgery 10 (24%) patients reported de‐novo SUI. This resolved with time and pelvic floor muscle training such that at 12 months only 5 (12%) reported continued SUI. There was 1 symptomatic diverticulum recurrence (1.4%). Conclusions The commonest presenting symptom of a female urethral diverticulum is urethral pain followed by dysuria and dyspareunia. Surgical excision with Martius fat pad interposition results in complete resolution of symptoms in the majority of women. The incidence of persistent de novo SUI in an expert high‐volume centre is 12%. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-13T11:20:32.977848-05:
      DOI: 10.1111/bju.13579
  • Testosterone treatment is not associated with increased risk of prostate
           cancer or worsening of lower urinary tract symptoms: Prostate health
           outcomes in the Registry of Hypogonadism in Men (RHYME)
    • Abstract: Objectives To evaluate the effects of testosterone replacement therapy (TRT) on prostate health indicators in hypogonadal men, including rates of prostate cancer diagnoses, changes in PSA levels and lower urinary tract symptoms (LUTS) over time. Materials and Methods The Registry of Hypogonadism in Men (RHYME) is a multi‐national patient registry of treated and untreated, newly‐diagnosed hypogonadal men (n=999). Follow‐up assessments were performed at 3‐6, 12, 24, and 36 months. Baseline and follow‐up data collection included medical history, physical examination, blood sampling, and patient questionnaires. Prostate biopsies were subjected to blinded, independent adjudication for presence and severity of prostate cancer (PCa), Prostate Specific Antigen (PSA), and Testosterone (T) levels measured via local and central laboratory assays, and LUTS severity via the International Prostate Symptom Score (IPSS). Incidence rates per 100,000 person‐years were calculated. Longitudinal mixed models were used to assess effects of T on PSA and IPSS. Results Of 999 patients with clinically‐diagnosed HG, 750 (75%) initiated TRT, contributing 23,900 person‐months of exposure. Mean T levels increased from 8.3 to 15.4 nmol/L in treated men, compared to only a slight increase from 9.4 nmol/L to 11.3 nmol/L in untreated men. Fifty‐five (55) biopsies were performed for suspected prostate cancer, and 12 non‐cancer related biopsies were performed for other reasons. Overall, the proportion of positive biopsies was nearly identical in men on T (37.5%) compared to those not on T (37.0%) over the course of the study. No differences were observed in PSA levels, total IPSS score, or IPSS obstructive sub‐scale score by testosterone treatment status. Lower IPSS irritative sub‐scale scores were reported in treated men compared to untreated men. Conclusions Results support prostate safety of TRT in newly diagnosed men with hypogonadism (HG). This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-13T11:15:33.045254-05:
      DOI: 10.1111/bju.13578
  • Socioeconomic factors and penile cancer risk and mortality; a
           population‐based study
    • Abstract: Objective To investigate possible associations between socioeconomic status (SES) and penile cancer risk, stage at diagnosis, and mortality. Patients/subjects and methods A population‐based register study including men in Sweden diagnosed with penile cancer between 2000 and 2012 (1676 men) and randomly chosen controls (9872 men). Data were retrieved from the National Penile Cancer Register (NPECR) and several other population‐based healthcare and sociodemographic registers. Educational level, disposable income, marital status, and number of individuals in the household, were assessed as indicators of SES. The risk of penile cancer and penile cancer death in relation to SES were estimated using logistic regression and proportional hazards models, respectively. Cumulative cause‐specific mortality (CSM) estimates by SES were calculated using the Kaplan–Meier method. Results A low educational level and low disposable income were associated with an increased risk of invasive penile cancer. Furthermore, low educational level was associated with more advanced primary tumour stage. Divorced and never married men had a generally increased risk of penile cancer and were diagnosed with more advanced primary tumour stages. However, neither educational level nor marital status was associated with lymph node or distant metastases. Also, men in single‐person households had an increased risk of both non‐invasive and invasive disease. In men with invasive penile cancer, there were no significant associations of indicators of SES and CSM. Conclusions Low educational level, low disposable income, being divorced or never married, and living in a single‐person household, all increase the risk of advanced stage penile cancer, but not lymph node or distant metastases. The assessed indicators of SES did not influence penile CSM. In conclusion, our findings indicates that SES influences the risk and stage of penile cancer, but not survival.
      PubDate: 2016-07-04T02:50:40.003606-05:
      DOI: 10.1111/bju.13534
  • Prediction of Pathologic Stage Based on Clinical Stage, Serum PSA, and
           Biopsy Gleason Score: Partin Tables in the Contemporary Era
    • Authors: Jeffrey J. Tosoian; Meera Chappidi, Zhaoyong Feng, Elizabeth B. Humphreys, Misop Han, Christian P. Pavlovich, Jonathan I. Epstein, Alan W. Partin, Bruce J. Trock
      Abstract: Objective ‐To update the Partin Tables for prediction of pathological stage in the contemporary setting and examine trends in patients treated with radical prostatectomy (RP) over the past three decades. Patients and Methods ‐From January 2010 through October 2015, a total of 4459 men meeting inclusion criteria underwent RP and pelvic lymphadenectomy for histologically‐confirmed prostate cancer at the Johns Hopkins Hospital. ‐Preoperative clinical stage, serum prostate‐specific antigen (PSA) level, and biopsy Gleason score (i.e. prognostic Grade Group) were utilized in a polychotomous logistic regression model to predict the probability of pathological outcomes categorized as: organ‐confined (OC), extraprostatic extension (EPE), seminal vesicle involvement (SV+), or lymph node involvement (LN+). ‐Preoperative characteristics and pathological findings in men treated with RP since 1983 were collected and clinical‐pathological trends were described. Results ‐Median age at surgery was 60 years (range 34‐77) and median PSA was 4.9 ng/ml (0.1‐125.0). ‐The observed probabilities of pathological outcomes were: OC disease in 74%, EPE in 20%, SV+ in 4%, and LN+ in 2%. ‐The probability of EPE increased substantially when biopsy Gleason score increased from 6 (Grade Group 1) to 3+4 (Grade Group 2), with smaller increases for higher grades. The probability of LN+ was substantially higher for biopsy Gleason score 9‐10 (Grade Group 5) as compared to lower Gleason scores. ‐Area under the receiver operating characteristic curves for binary logistic models predicting EPE, SV+, and LN+ versus OC were 0.724, 0.856, and 0.918, respectively. ‐The proportion of men treated with biopsy Gleason score ≤6 cancer (Grade Group 1) was 47%, representing a substantial decrease from 63% in the previous cohort and 77% in 2000‐2005. The proportion of men with organ‐confined cancer has remained similar during that time, equaling 73% to 74% overall. ‐The proportions of men with SV+ (4.1% from 3.4%) and LN+ (2.3% from 1.4%) increased relative to the preceding era for the first time since the Partin tables were introduced in 1993. Conclusions ‐The Partin Tables remain a straightforward and accurate approach for projecting pathological outcomes based on readily available clinical data. ‐Acknowledging these data are derived from a tertiary care referral center, the proportion of men with OC disease has remained stable since 2000, despite a substantial decline in the proportion of men with biopsy Gleason score 6 (Grade Group 1). This is consistent with the notion that many men with Gleason score 6 (Grade Group 1) disease were overtreated in previous eras. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-01T09:40:24.014302-05:
      DOI: 10.1111/bju.13573
  • Primary Gleason Pattern Upgrading in contemporary D'Amico low‐risk
           prostate cancer patients: Implications for future biomarkers and imaging
    • Abstract: Objective To retrospectively assess the rate of primary Gleason upgrading (HGPGU) to primary Gleason pattern 4 or 5 in a contemporary cohort of D'Amico low‐risk prostate cancer (PCa) and PRIAS active surveillance (AS) patients and to develop a tool for HGPGU prediction. HGPGU is a contraindication in most AS and focal therapy protocols. Methods 10,616 patients with localized PCa were treated at a high volume European tertiary care center from 2010 to 2015 with radical prostatectomy. Analyses were restricted to 1,819 D'Amico low‐risk patients (17.1%) with PSA
      PubDate: 2016-07-01T09:27:08.321457-05:
      DOI: 10.1111/bju.13570
  • Contemporary retroperitoneal lymph node dissection (RPLND) for testis
           cancer in the UK – a national study
    • Authors: H Wells; M C Hayes, T O'Brien, S Fowler,
      Abstract: Objectives To undertake a comprehensive prospective national study of the outcomes of RPLND for testis cancer over a one year period in the United Kingdom. Patients and Methods Data were submitted online using the BAUS Section of Oncology Data and Audit System. All new patients undergoing RPLND for testis cancer between March 2012 and February 2013 were studied prospectively. Data was analysed using Tableau software and case ascertainment compared with Hospital Episode Statistics (HES) data. Results 162 men underwent RPLND by 20 surgeons in 17 centres. Mean case volume per centre was 9 (range 2 – 32) per centre and median case volume per surgeon 6 (1 – 30). Indication was residual mass post‐chemotherapy (73%); primary treatment (6%); relapse (14%); salvage (7%). Median time to surgery post chemotherapy was 8 – 12 weeks (12 weeks). 91% of procedures utilised open surgery. Median operating time was 3 – 4 hours (6 hours). Nerve sparing was performed in 67% (19% bilateral; 48% unilateral). Dissection was template in 81% and lumpectomy in 16%. 25% required additional intra‐operative procedures including 11% synchronous planned nephrectomy. 157/160 (98%) of recorded RPLND operations were completed. One was terminated due to bleeding and in two the mass could not be removed. There were no deaths within 30 days of surgery. 75% of men did not require a blood transfusion, 15% required 1 – 2 units and 10% received more than two units. 10% of men had post‐operative complications (Clavien grade 1 = 7, grade 2 = 7, grade 3 = 1). Mean length of stay was 5.5 days (range 1‐59). Histology showed necrosis in 22%; teratoma differentiated in 42%; and residual cancer in 36%. Conclusion This prospective collaborative national study describes for the first time the surgical outcomes after RPLND across the UK. The quality of RPLND in the UK appears high. The study can act as a benchmark for this type of surgery across the world. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-29T06:46:31.819732-05:
      DOI: 10.1111/bju.13569
  • PI‐RADS 4 or more: Active Surveillance no more
    • Authors: Marlon Perera; Nik Katelaris, Declan Murphy, Shannon McGrath, Nathan Lawrentschuk
      Abstract: The introduction of multiparametric Magnetic Resonance Imaging (mpMRI) has improved the diagnosis and risk stratification of intermediate and high‐risk prostate cancer. In addition to diagnosis, mpMRI has increasing become a useful tool for monitoring prostate cancer risk of patients on active surveillance (AS) programs. A significant proportion of men on AS programs have suspicious lesions on mpMRI [1]. Accordingly, repeat mpMRI provides means of non‐invasive assessment with the potential for fusion biopsy and preferential sampling of prostate cancer tissue. In 2012, the Prostate Imaging Reporting and Data System (PI‐RADS) introduced standardized reporting of prostate mpMRI. PI‐RADS 4 and 5 lesions have been classified as “clinically significant cancer is likely to be present” and “clinically significant cancer is highly likely” respectively. PI‐RADS 4 and 5 lesions are being increasing correlated with intermediate and high‐grade prostate cancer. As recently discussed in: “Gleason Pattern 4: Active Surveillance no more” [2], patients with intermediate‐risk prostate cancer are not suitable for AS. In light of this, the presence of PI‐RADS 4 or 5 lesions on men enrolled to AS programs for prostate cancer warrants concern. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-22T09:15:58.511445-05:
      DOI: 10.1111/bju.13562
  • The contemporary landscape of occupational bladder cancer within the
           United Kingdom: A meta‐analysis of risks over the last 80 years
    • Authors: Marcus G Cumberbatch; Ben Windsor Shellard, James WF Catto
      Abstract: Importance Bladder cancer (BC) is a common malignancy that arises through occupational carcinogen exposure. Here we analyse trends in UK to better understand contemporary occupational BC. Objective To profile the contemporary risks of occupational BC in the UK. Materials and methods Systematic review using PubMed, Medline, Embase and Web of Science was performed in March 2016. We selected reports of British workers in which BC or occupation were the main focus, with sufficient cases or with confidence intervals (CI). We used the most recent data in populations with multiple reports. We combined odds ratios and risk ratios (RRs) to provide pooled RRs of incidence and disease specific mortality (DSM). We tested for heterogeneity and publication bias. We extracted BC mortality from Office of National Statistics death certificates. We compered across regions and with our meta‐analysis. Results We identified 25 articles reporting risks in 702,941 persons. Meta‐analysis revealed significantly increased incidence for 12/37 and DSM for 5/37 occupational classes. Three classes had reduced BC risks. The greatest risk of BC incidence occurred in chemical process (RR 1.87 (1.50‐2.34)), rubber (RR 1.82 (1.4‐2.38)) and dye workers (RR 1.8, (1.07‐3.04)). The greatest risk of DSM occurred in electrical (RR 1.49 (1.19‐1.87)) and chemical process workers (RR 1.35 (1.09‐1.68)). BC mortality was higher in the North of England, probably reflecting smoking patterns and certain industries. Limitations include the lack of sufficient robust data, missing occupational tasks and no adjustment for smoking. Conclusion Occupational BC occurs in many workplaces and the risks for incidence and DSM may differ. Regional differences may reflect changes in industry and smoking patterns. Relatively little is known about BC within British industry, suggesting official data underestimate the disease. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-22T09:10:59.217584-05:
      DOI: 10.1111/bju.13561
  • What is the outcome of paediatric gastrocystoplasty when the patients
           reach adulthood'
    • Abstract: Objective To document the long‐term outcomes of paediatric augmentation gastrocystoplasty (AGC) in terms of preservation of renal function and maintenance of dryness, and to analyse the rate of complications. Patients and methods The medical records of children who had undergone AGC between 1992 and 2000 (minimum time interval of 15 years) were reviewed retrospectively. The following data were collected: age at surgery, the cause of bladder dysfunction, functioning of the AGC, any complications and the long‐term outcome of the patients. All of the patients were recontacted by telephone. Results A total of 11 AGCs were carried out between 1992 and 2000, at a median age of 11 years (range from 6.5 to 14 years). The diagnosis of patients undergoing AGC included myelomeningocele (n=4), bladder exstrophy (n=4), posterior urethral valves (n=1), irradiated bladder (n=1) and Prune Belly syndrome (n=1). Median follow‐up was 17 years (15‐19.5, all patients). Renal function was preserved or improved in 63% of patients and 80% of patients were dry after AGC. Seven of the 11 (63%) patients reported symptoms linked to haematuria‐dysuria syndrome, which was resistant to treatment in one case and requiring excision of the gastric patch. Three of the 11 patients (23%) developed a tumour on the gastric graft after a median delay of 20 years (range 11‐22) after the initial procedure. All had gastric adenocarcinoma of which two were metastatic at the time of diagnosis requiring pelvectomy with pelvic lymph nodes dissection and adjuvant chemotherapy. Seven of the 11 (63%) patients underwent excision of the gastric patch after a median time of 11 years (range 8.5‐20.5). Conclusions Our long‐term data confirmed that the majority of patients undergoing AGC had preservation of their renal function and were continent. However, long‐term, AGC was associated with a significant risk of malignant transformation and a high rate of surgical re‐intervention involving removal of the gastric patch. These results question the use of this technique for bladder augmentation, irrespective of the indication. We highlighted the importance of strict endoscopic follow‐up of all patients already having undergone an AGC and the need to inform and educated patients about tumour‐related symptoms. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-20T09:31:08.134243-05:
      DOI: 10.1111/bju.13558
  • Treatment patterns, testicular loss, and disparities in inpatient surgical
           management of testicular torsion in boys: a population based study
    • Abstract: Objectives To examine temporal trends in inpatient testicular torsion (TT) treatment and testicular loss (TL), and identify risk‐factors for TL utilizing a large nationally representative pediatric cohort, stratified to established high prevalence TT cohorts (neonatal TT [NTT,
      PubDate: 2016-06-20T09:20:23.663547-05:
      DOI: 10.1111/bju.13557
  • Preoperative nomogram to predict likelihood of complications following
           radical nephroureterectomy
    • Abstract: objectives To construct a nomogram based on preoperative variables to better predict the likelihood of a complication occurring within 30‐days of radical nephroureterectomy (RNU). patients and methods The charts of 731 patients undergoing RNU at 8 academic medical centers between 2002 and 2014 were reviewed. Preoperative clinical, demographic, and comorbidity indices were collected. Complications occurring within 30‐days of surgery were graded using the modified Clavien‐Dindo scale. Multivariate logistic regression determined the association between preoperative variables and post‐RNU complications. A nomogram was created from the reduced multivariate model with internal validation using the bootstrapping technique with 200 repetitions. Results 408 men and 323 women with a median age of 70 years and BMI of 27 were included. 75% of the cohort was of white race, 18% had an ECOG performance status ≥ 2, 20% had a Charlson Comorbidity Index > 5, and 50% had baseline CKD stage III or greater. Overall, 279 patients (38%) experienced a complication including 61 (22%) with Clavien III or greater events. A multivariate model identified 5 variables associated with complications including patient age, race, ECOG performance status, CKD stage, and Charlson comorbidity index. A preoperative nomogram incorporating these risk factors was constructed with an area under curve of 72.2%. conclusions Using standard preoperative variables from this multi‐institutional RNU experience, we constructed and validated a nomogram for predicting perioperative complications after RNU. Such information may permit more accurate risk stratification on an individual cases basis prior to major surgery. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-20T09:15:24.530153-05:
      DOI: 10.1111/bju.13556
  • The Origins of Urinary Stone Disease: Upstream mineral formations initiate
           downstream Randall's plaque
    • Authors: Ryan S. Hsi; Krishna Ramaswamy, Sunita P Ho, Marshall L. Stoller
      Abstract: Objectives To describe a new hypothesis for the initial events leading to urinary stones. A biomechanical perspective on Randall's plaque formation through form and function relationships is applied to functional units within the kidney we have termed the “medullo‐papillary complex” – a dynamic relationship between intratubular and interstitial mineral aggregates. Materials and Methods A complete MEDLINE search was performed to examine the existing literature regarding the anatomical and physiological relationships in the renal medulla and papilla. Sectioned human renal medulla with papilla from radical nephrectomy specimens were imaged using a high resolution micro X‐ray computed tomography. The location, distribution, and density of mineral aggregates within the medullo‐papillary complex were identified. Results Mineral aggregates were observed proximally in all specimens within the outer medulla of medullary complex and were intratubular. Distal interstitial mineralization at the papillary tip corresponding to Randall's plaque was not observed until a threshold of proximal mineralization was observed. Mineral density measurements suggest varied chemical compositions between the proximal intratubular (330 mg/cc) and distal interstitial (270 mg/cc) deposits. A review of the literature revealed distinct anatomical compartments and gradients across the medullo‐papillary complex that supports the empirical observations that mineralization proximally triggers distal Randall's plaque formation. Conclusion The initial stone event is initiated by intratubular mineralization of the renal medullary tissue leading to the interstitial mineralization that is observed as Randall's plaque. We base this novel hypothesis on a multiscale biomechanics perspective involving form and function relationships, and empirical observations. Additional studies are needed to validate this hypothesis. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-16T03:30:30.104098-05:
      DOI: 10.1111/bju.13555
  • Spectrum of genomic alterations in FGFR3: current appraisal of the
           potential role of FGFR3 in advanced urothelial carcinoma
    • Authors: N. Sethakorn; P. H. O'Donnell
      Abstract: Molecular analysis has identified subsets of urothelial carcinoma (UC) expressing distinct genetic signatures. Genomic alterations in the oncogenic fibroblast growth factor receptor 3 (FGFR3) pathway are among the most well‐described in UC and have led to extensive and ongoing investigation of FGFR3‐targeted therapies in this disease, although no new drugs have yet been approved. Given the unmet need for effective treatments in advanced and metastatic UC, a better understanding of the known molecular alterations of FGFR3 and of the prior and ongoing clinical investigations of this promising target in UC deserve attention. The objective of this review is to describe the landscape of alterations and biology of FGFR3 in UC, comprehensively summarize the current state of UC clinical trials of FGFR3 inhibitors, and discuss future therapeutic applications. Using the Pubmed and Clinicaltrials. gov databases, articles describing the spectrum and biological activity of FGFR3 genomic alterations and trials of FGFR3 inhibitors in UC were identified. Search terms included “FGFR3 genomic alterations” and “urothelial cancer” or “bladder cancer.” Genomic alterations including translocations and activating mutations are increasingly described in advanced and metastatic UC. The majority of clinical trials have been performed in unselected populations. However, recent studies have reported encouraging preliminary data. We argue that routine use of molecular genomic tumor analysis in UC may inform selection of patients for appropriate trials and further investigate the potential for FGFR3 as a meaningful clinical target for this difficult disease. This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-07T10:05:45.180624-05:
      DOI: 10.1111/bju.13552
  • Cost‐effectiveness of zoledronic acid and strontium‐89 as bone
           protecting treatments in addition to chemotherapy in patients with
           metastatic castrate‐refractory prostate cancer: results from the TRAPEZE
           trial (ISRCTN 12808747)
    • Authors: L Andronis; I Goranitis, S Pirrie, A Pope, D Barton, S Collins, A Daunton, D McLaren, J O'Sullivan, C Parker, E Porfiri, J Staffurth, A Stanley, J Wylie, S Beesley, A Birtle, J Brown, P Chakraborti, S Hussain, M Russell, L Billingham, N James
      Abstract: Objectives To evaluate the cost‐effectiveness of adding zoledronic acid (ZA) or strontium‐89 (Sr89) to standard docetaxel chemotherapy for patients with castrate‐refractory prostate cancer (CRPC). Patients and methods Data on resource use and quality of life for 707 patients collected prospectively in the TRAPEZE 2x2 factorial randomised trial (ISRCTN 12808747) were used to assess the cost‐effectiveness of i) zoledronic acid versus no zoledronic acid (ZA vs. no ZA), and ii) strontium‐89 versus no strontium‐89 (Sr89 vs. no Sr89). Costs were estimated from the perspective of the NHS and included expenditures for trial treatments, concomitant medications and use of related hospital and primary care services. QALYs were calculated according to patients’ responses to the generic EuroQol EQ‐5D‐3L instrument. Results are expressed as incremental cost‐effectiveness ratios (ICER) and cost‐effectiveness acceptability curves. Results The per‐patient cost for ZA was £12,667, £251 higher than the equivalent cost in the no ZA group. Patients in the ZA group experienced on average 0.03 QALYs more than their counterparts in no ZA. The incremental cost‐effectiveness ratio (ICER) for this comparison was £8,005. Sr89 was associated with a cost of £13,230, £1,365 higher than no Sr89, and a gain of 0.08 QALYs compared to no Sr89. The ICER for Sr89 was £16,884. The probabilities of ZA and Sr89 being cost‐effective were 0.64 and 0.60, respectively. Conclusions The addition of bone‐targeting treatments to standard chemotherapy led to a small improvement in QALYs for a modest increase in cost (or cost‐savings). ZA and Sr89 resulted in ICERs below conventional willingness‐to‐pay per QALY thresholds, suggesting that their addition to chemotherapy may represent a cost‐effective use of resources This article is protected by copyright. All rights reserved.
      PubDate: 2016-06-03T04:00:39.500191-05:
      DOI: 10.1111/bju.13549
  • Estimating the risks and benefits of Active Surveillance protocols for
           Prostate Cancer: A microsimulation study
    • Authors: Tiago M. de Carvalho; Eveline A.M. Heijnsdijk, Harry J. de Koning
      Abstract: Objective To estimate the increase in prostate cancer mortality (PCM) and the reduction in overtreatment resulting from different Active Surveillance (AS) protocols, compared to treating men immediately. Subjects and Methods We use a microsimulation model (MISCAN‐Prostate), with natural history based on ERSPC data. We estimate probabilities of referral to radical treatment while on AS, depending on disease stage, with data from John Hopkins AS cohort. We sample 10 million men representative of the US population and we project the effects of applying AS protocols differing by time between biopsies, compared to treating men immediately. Results AS with yearly follow‐up biopsies for low‐risk patients (≤ T2a‐stage and Gleason 6) increases the probability of PCM to 2.6% (1% increase) and reduces overtreatment from 2.5% to 2.1% (18.4% reduction). With biopsies every three years after the first year, PCM increases by 2.3% and overtreatment reduces from 2.5% to 1.9% (30.3% reduction). Including intermediate‐risk men (> T2a‐stage or Gleason 3+4) in AS increases PCM by 2.7% and reduces overtreatment from 2.5% to 2.0% (23.1% reduction). These results may not apply to African‐American men. Conclusions Offering AS for low‐risk patients is relatively safe. Increasing the biopsy interval from yearly to up to every 3 years after the first year, will significantly reduce overtreatment among low‐risk men, with limited PCM risk. This article is protected by copyright. All rights reserved.
      PubDate: 2016-05-25T00:54:12.656075-05:
      DOI: 10.1111/bju.13542
  • Issue Information ‐ TOC
    • First page: 485
      PubDate: 2016-09-14T06:52:29.415693-05:
      DOI: 10.1111/bju.13297
  • Issue Information ‐ JEB
    • First page: 488
      PubDate: 2016-09-14T06:52:27.601905-05:
      DOI: 10.1111/bju.13298
  • Issue Information ‐ Jnl info
    • First page: 490
      PubDate: 2016-09-14T06:52:23.047862-05:
      DOI: 10.1111/bju.13299
  • Immunotherapy in urological malignancies: can you take your knowledge to
           the next level'
    • Authors: John W. Davis
      First page: 491
      PubDate: 2016-09-14T06:52:25.130483-05:
      DOI: 10.1111/bju.13648
  • Some prostate cancers are invisible to magnetic resonance imaging!
    • Authors: Leonard S. Marks
      First page: 492
      PubDate: 2016-09-14T06:52:24.762498-05:
      DOI: 10.1111/bju.13440
  • Cutaneous ureterostomy: ‘back to the future’
    • Authors: Fiona C. Burkhard; Patrick Y. Wuethrich
      First page: 493
      PubDate: 2016-09-14T06:52:29.07727-05:0
      DOI: 10.1111/bju.13532
  • HOXB13 mutations and prostate cancer risk
    • First page: 496
      PubDate: 2016-09-14T06:52:24.295613-05:
      DOI: 10.1111/bju.13477
  • Immune check point blockade ‐ a treatment for Urological
    • Authors: Oussama Elhage; Christine Galustian, Prokar Dasgupta
      First page: 498
      Abstract: In the last few years there have been concerted attempts at using the power of the immune system as an effective treatment option for cancer. This has become possible since our understanding of the workings of the immune system improved. Tumours form because of failure of the organism to destroy a rogue, mutated cell in an appropriate way. This article is protected by copyright. All rights reserved.
      PubDate: 2016-07-01T09:27:33.253204-05:
      DOI: 10.1111/bju.13571
  • No evidence (yet) to support the statement ‘lower urinary tract symptoms
    • First page: 500
      PubDate: 2016-03-14T07:07:47.631668-05:
      DOI: 10.1111/bju.13456
  • Validation of the novel International Society of Urological Pathology 2014
           five‐tier Gleason grade grouping: biochemical recurrence rates for 3+5
           disease may be overestimated
    • Authors: Roderick C.N. Bergh; Theo H. Kwast, Jeroen Jong, Homayoun Zargar, Andrew J. Ryan, Anthony J. Costello, Declan G. Murphy, Henk G. Poel
      First page: 502
      PubDate: 2016-04-01T07:35:45.956328-05:
      DOI: 10.1111/bju.13478
  • Recent advances in immuno‐oncology and its application to urological
    • Authors: Jennifer M. Mataraza; Philip Gotwals
      First page: 506
      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 tumours, and increase the rate of durable clinical responses.
      PubDate: 2016-06-03T10:05:24.354366-05:
      DOI: 10.1111/bju.13518
  • Predictive value of negative 3T multiparametric magnetic resonance imaging
           of the prostate 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
      First page: 515
      Abstract: Objectives To evaluate the cancer detection rates for men undergoing 12‐core systematic prostate biopsy with negative prebiopsy multiparametric magnetic resonance imaging (mpMRI) results. Materials and Methods Clinical data from consecutive men undergoing prostate biopsy who had undergone prebiopsy 3T mpMRI from December 2011 to August 2014 were reviewed from an institutional review board‐approved prospective database. Men with negative prebiospy mpMRI results (negMRI) before biopsy were identified for the present analysis. Clinical features, cancer detection rates and negative predictive values were summarized. Results Seventy five men with negMRI underwent systematic 12‐core biopsy during the study period. In the entire cohort, men with no previous biopsy, men with previously negative biopsy and men enrolled in active surveillance protocols, the overall cancer detection rates were 18.7, 13.8, 8.0 and 38.1%, respectively, and the detection rates for Gleason score (GS) ≥7 cancer were 1.3, 0, 4.0 and 0%, respectively. The NPVs for all cancers were 81.3, 86.2, 92.0, and 61.9, and for GS ≥7 cancer they were 98.7, 100, 96.0 and 100%, respectively. Conclusions A negative prebiopsy mpMRI confers an overall NPV of 82% on 12‐core biopsy for all cancer and 98% for GS ≥7 cancer. Based on 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.
      PubDate: 2016-02-25T23:07:28.572673-05:
      DOI: 10.1111/bju.13427
  • Complications and quality of life in elderly patients with several
           comorbidities undergoing 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
      First page: 521
      Abstract: Objectives To compare peri‐operative outcomes and quality of life (QoL) in a series of elderly patients with high comorbidity status who underwent single stoma cutaneous ureterostomy (CU) or ileal conduit (IC) after radical cystectomy (RC). Patients and Methods The clinical records of patients aged >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 analysed. 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 postoperative outcomes were evaluated and compared between the two groups. In addition, the Bladder Cancer Index (BCI) was used to assess QoL. Results A total of 70 patients were included in the final comparative analyses. Of these, 35 underwent IC diversion and 35 CU single stoma diversion. The two groups were similar with regard to age, gender, ASA score, type of indication and pathological features. Operating times (P < 0.001), estimated blood loss (P < 0.001), need for intensive care unit stay (P = 0.01), time to drain removal (P < 0.001) and length of hospital stay (P < 0.001) were significantly higher in patients undergoing IC diversion. The number of patients with intra‐ (P = 0.04) and early postoperative (P = 0.02) complications was also significantly higher among those undergoing IC diversion. Interestingly, the mean BCI scores were overlapping in the two groups. Conclusions The present results show that CU with a single stoma can represent a valid alternative to IC in elderly patients with relevant comorbidities, reducing peri‐operative complications without a significant impairment of QoL.
      PubDate: 2016-04-04T00:21:03.094172-05:
      DOI: 10.1111/bju.13462
  • Validation of a bone scan positivity risk table in non‐metastatic
           castration‐resistant prostate cancer
    • Authors: Stephen J. Freedland; Lauren E. Howard, Brian T. Hanyok, Vishnu K. Kadiyala, Jameson Y. Kuang, Colette A. Whitney, Floyd R. Wilks, Christopher J. Kane, Martha K. Terris, Christopher L. Amling, Matthew R. Cooperberg, William J. Aronson, Daniel M. Moreira
      First page: 570
      Abstract: Objectives To test the external validity of a previously developed risk table, designed to predict the probability of a positive bone scan among men with non‐metastatic (M0) castration‐resistant prostate cancer (CRPC), in a separate cohort. Patients and Methods We retrospectively analysed 429 bone scans of 281 patients with CRPC, with no known previous metastases, treated at three Veterans Affairs Medical Centers. We assessed the predictors of a positive scan using generalized estimating equations. Area under the curve (AUC), calibration plots and decision‐curve analysis were used to assess the performance of our previous model to predict a positive scan in the current data. Results A total of 113 scans (26%) were positive. On multivariable analysis, the only significant predictors of a positive scan were log‐transformed prostate‐specific antigen (PSA): hazard ratio (HR) 2.13; 95% confidence interval (CI) 1.71–2.66 (P < 0.001) and log‐transformed PSA doubling time (PSADT): HR 0.53; 95% CI 0.41–0.68 (P < 0.001). Among men with a PSA level
      PubDate: 2016-02-08T10:01:55.87093-05:0
      DOI: 10.1111/bju.13405
  • MicroRNA‐30a as a prognostic factor in urothelial carcinoma of bladder
           inhibits cellular malignancy by antagonising Notch1
    • Authors: Chao Zhang; Xin Ma, Jun Du, Zhiyong Yao, Taoping Shi, Qing Ai, Xusheng Chen, Zhenting Zhang, Xu Zhang, Xin Yao
      First page: 578
      Abstract: Objective To explore the relation between microRNA‐30a (miR‐30a) and Notch1, and to evaluate the potential prognostic role of miR‐30a in invasive urothelial carcinoma of the bladder (UCB). Patients and methods In all, 50 invasive UCB tissue specimens, along with the adjacent bladder tissue specimens were obtained, and the clinical parameters of the 50 patients were analysed. Bioinformatics analysis was performed and miR‐30a was selected as a potential miRNA targeting Notch1, with a luciferase assay performed to verify the binding site between miR‐30a and Notch1. Quantitative real‐time reverse transcriptase‐polymerase chain reaction was used to assess the RNA expressions of miR‐30a and Notch1, while Western Blotting and immunohistochemical staining were used to assess the protein expression of Notch1. Finally, cell proliferation, cell cycle, cell migration and invasion assays were used to evaluate the cellular effects of miR‐30a and Notch1 on the UCB cell lines T24 and 5637. Results MiR‐30a was downregulated in tumour tissues when compared with adjacent bladder tissues (P < 0.001), negatively correlating with Notch1 messenger RNA (R2 0.106, P = 0.021) in invasive UCB, and miR‐30a expression further decreased in patients with shorter overall survival and disease‐free survival (P = 0.039 and P = 0.037, respectively). The luciferase assay showed that miR‐30a inhibited the Notch1 3′‐untranslated region reporter activities in the T24 and 5637 cell lines (both P < 0.001). Both miR‐30a and small interfering RNA Notch1 negatively regulated cell proliferation (P = 0.002 and P = 0.035 in T24; P = 0.029 and P = 0.037 in 5637 cell lines), activated cell cycle arrest (both P < 0.001 in T24; both P < 0.001 in 5637 cell lines), and prevented cellular migration (both P < 0.001 in T24; P = 0.003 and P < 0.001 in 5637 cell lines) and invasion (P = 0.009 and P = 0.006 in T24; P = 0.006 and P = 0.002 in 5637 cell lines) abilities. Ectopic Notch1 without the 3′untranslated region partially rescued the above‐mentioned cellular effects of over‐expressed miR‐30a on T24 and 5637 cells. Conclusions MiR‐30a lessens cellular malignancy by antagonising oncogene Notch1 and plays an effective prognostic role in invasive UCB.
      PubDate: 2016-02-21T23:52:04.861617-05:
      DOI: 10.1111/bju.13407
  • Phase II trial of docetaxel, bevacizumab, lenalidomide and prednisone in
           patients with metastatic castration‐resistant prostate cancer
    • First page: 590
      Abstract: Objective To determine the safety and clinical efficacy of two anti‐angiogenic agents, bevacizumab and lenalidomide, with docetaxel and prednisone. Patients 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 (10 mg 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 25 mg daily for 2 weeks followed by 1 week off). Patients received supportive measures including prophylactic pegfilgrastim and enoxaparin. The primary endpoints were safety and clinical efficacy. Results A total of 63 patients enrolled in this trial. Toxicities were manageable with most common adverse events (AEs) being haematological, and were ascertained by weekly blood counts. Twenty‐nine patients (46%) had grade 4 neutropenia, 20 (32%) had grade 3 anaemia and seven (11%) had grade 3 thrombocytopenia. Despite frequent neutropenia, serious infections were rare. Other common non‐haematological grade 3 AEs included fatigue (10%) and diarrhoea (10%). Grade 2 AEs in >10% of patients included anorexia, weight loss, constipation, osteonecrosis of the jaw, rash and dyspnoea. Of 61 evaluable patients, 57 (93%), 55 (90%) and 33 (54%) had PSA declines of >30, >50 and >90%, respectively. Of the 29 evaluable patients, 24 (86%) had a confirmed radiographic partial response. The median times to progression and overall survival were 18.2 and 24.6 months, respectively. Conclusions With appropriate supportive measures, combination angiogenesis inhibition can be safely administered and potentially provide clinical benefit. These hypothesis‐generating data would require randomized trials to confirm the findings.
      PubDate: 2016-02-19T03:28:38.524212-05:
      DOI: 10.1111/bju.13412
  • Plasma fibrinogen level: an independent prognostic factor for
           disease‐free survival and cancer‐specific survival in patients with
           localised renal cell carcinoma
    • Authors: Jun Obata; Nobuyuki Tanaka, Ryuichi Mizuno, Kent Kanao, Shuji Mikami, Kazuhiro Matsumoto, Takeo Kosaka, Eiji Kikuchi, Masahiro Jinzaki, Mototsugu Oya
      First page: 598
      Abstract: Objectives To investigate the impact of perioperative plasma fibrinogen level as a biomarker of oncological outcome in localised renal cell carcinoma (RCC). Patients and methods We consecutively identified 601 patients with localised RCC who underwent curative surgery at a single institution. Subsequent disease recurrence and cancer‐specific survival (CSS) 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 threshold level of preoperative plasma fibrinogen of ≥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 survival and CSS rates between patients with and without preoperative plasma fibrinogen levels of ≥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 normalisation of plasma fibrinogen level was significantly associated with CSS, showing that patients with non‐normalised 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 tumour metastasis and cancer‐specific mortality, while there was a significant difference in CSS between patients in the normalised and non‐normalised 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.
      PubDate: 2016-02-19T03:31:51.202232-05:
      DOI: 10.1111/bju.13414
  • Robot‐assisted Fallopian tube transection and anastomosis using the new
           REVO‐I robotic surgical system: feasibility in a chronic porcine model
    • Authors: Ali Abdel Raheem; Irela Soto Troya, Dae Keun Kim, Se hoon Kim, Park Dong Won, Park Sung Joon, Gim Soo Hyun, Koon Ho Rha
      First page: 604
      Abstract: Objectives To evaluate the feasibility and safety of the new REVO‐I robotic platform by performing Fallopian tube transection and anastomosis in live porcine models. Subjects 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 intra‐operative variables and the complications or difficulties arising when using the REVO‐I. Results Fallopian tube anastomosis was successfully performed in four porcine models. The mean (range) operating time was 66 (46–104 min), docking time 22.25 (14–53) min and console time 18 (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 bedside assistants reported ease of use and better performance with subsequent procedures. All pigs were alive 2 weeks after surgery, with no peri‐operative complications related to the use of the robot. Conclusions This preclinical chronic porcine study showed 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 will be to demonstrate its safety in humans.
      PubDate: 2016-05-26T19:45:41.212882-05:
      DOI: 10.1111/bju.13517
  • A retrospective analysis of laparoscopic partial nephrectomy with
           segmental renal artery clamping and factors that predict postoperative
           renal function
    • Authors: Pu Li; Chao Qin, Qiang Cao, Jie Li, Qiang Lv, Xiaoxin Meng, Xiaobing Ju, Lijun Tang, Pengfei Shao
      First page: 610
      Abstract: Objective To evaluate the feasibility and efficiency of laparoscopic partial nephrectomy (LPN) with segmental renal artery clamping, and to analyse the factors affecting postoperative renal function. Patients and methods We conducted 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) between September 2007 and July 2015 in our department. Blood loss, operating time, warm ischaemia time (WIT) and renal function were compared between groups. Univariable and multivariable linear regression analyses were applied to assess the correlations of selected variables with postoperative glomerular filtration rate (GFR) reduction. Volumetric data and estimated GFR of a subset of 60 patients in group B were compared with GFR to evaluate the correlation between these functional variables and preserved renal function after LPN. Results The novel technique slightly increased operating time, WIT and intra‐operative blood loss (P < 0.001), while it provided better postoperative renal function (P < 0.001) compared with the conventional technique. The blocking method and tumour characteristics were independent factors affecting GFR reduction, while WIT was not an independent factor. Correlation analysis showed that estimated GFR presented better correlation with GFR compared with kidney volume (R2 = 0.794 cf. R2 = 0.199) in predicting renal function after LPN. Conclusions LPN with segmental artery clamping minimizes warm ischaemia injury and provides 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.
      PubDate: 2016-06-19T23:15:59.483768-05:
      DOI: 10.1111/bju.13541
  • Biochemical composition of urolithiasis from stone dust – a
           matched‐pair analysis
    • Authors: Eleanor R. Ray; Gill Rumsby, R. Daron Smith
      First page: 618
      Abstract: Objective To determine if the biochemical composition of a renal calculus can be measured from ‘dust’ obtained during laser fragmentation. Patients and Methods This pilot study was set in a tertiary referral hospital between 2011 and 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 (
      PubDate: 2016-03-21T23:55:43.170589-05:
      DOI: 10.1111/bju.13448
  • Outcomes of single‐ vs double‐cuff artificial urinary sphincter
           insertion in low‐ and high‐risk profile male patients with severe
           stress urinary incontinence
    • First page: 625
      Abstract: Objectives To evaluate continence and complication rates of bulbar single‐cuff (SC) and distal bulbar double‐cuff (DC) insertion in male patients with severe stress urinary incontinence (SUI) according to whether the men were considered low or high risk for unfavourable artificial urinary sphincter (AUS) outcomes. Patients and Methods In all, 180 male patients who underwent AUS implantation between 2009 and 2013 were followed according to institutional standards. Patients with previous pelvic radiation therapy, open bulbar urethral or UI surgery (‘high risk’) underwent distal bulbar DC (123 patients) insertion, all others (‘low risk’) had proximal bulbar SC (57) insertion. Primary and secondary endpoints consisted of continence and complication rates. Kaplan–Meier analysis determined explantation‐free survival, and Cox regression models assessed risk factors for persistent UI and explantation. Results The median follow‐up was 24 months. Whereas there was no significant difference in pad usage/objective continence after SC vs DC insertion, superior rates of subjective/social continence and less persistent UI were reported by the patients with DC devices (all P ≤ 0.02). Overall, device explantation (erosion, infection or mechanical failure) occurred in 12.8% of patients. While early ( 0.05), DC patients had a 5.7‐fold higher risk of device explantation during late follow‐up (P = 0.02) and significantly shorter explantation‐free survival (log‐rank, P = 0.003). Conclusions Distal bulbar DC insertion in patients with a ‘high‐risk’ profile (previous pelvic radiation, urethral surgery) leads to similar objective continence, but higher explantation rates when compared with patients considered ‘low risk’ with proximal bulbar SCs. Randomised controlled trials comparing both devices will be needed to determine whether the higher explanations rates are attributable to the DC device or to underlying risk factors.
      PubDate: 2016-03-22T00:00:45.802828-05:
      DOI: 10.1111/bju.13449
  • Assessment of energy density usage during 180W lithium triborate laser
           photoselective vaporization of the prostate for benign prostatic
           hyperplasia. Is there an optimum amount of kilo‐Joules per gram of
    • First page: 633
      Abstract: Objectives To assess the effect of energy density (kJ/mL) applied on adenoma during photoselective vaporization of the prostate (PVP) treatment for benign prostate hyperplasia (BPH) on functional outcomes, prostate‐specific antigen (PSA) reduction and complications. Patients and Methods After exclusions, a total of 440 patients who underwent GreenLight tm laser XPS‐180W lithium triborate PVP for the treatment of BPH were retrospectively reviewed. Data were collected from seven different international centres (Canada, USA, UK and France). Patients were stratified into four energy density groups (kJ/mL) according to intra‐operative energy delivered and prostate volume as determined by preoperative transrectal ultrasonography (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 2‐year follow‐up.
      PubDate: 2016-04-16T02:00:39.334068-05:
      DOI: 10.1111/bju.13479
  • A survey of patient expectations regarding sexual function following
           radical prostatectomy
    • Authors: Serkan Deveci; Geoffrey T. Gotto, Byron Alex, Keith O'Brien, John P. Mulhall
      First page: 641
      Abstract: Objective To assess the understanding of patients, who had previously undergone radical prostatectomy (RP), about their postoperative sexual function, as clinical experience suggests that some RP patients have unrealistic expectations about their long‐term sexual function. Patients and Methods Patients presenting within 3 months of their open RP or robot‐assisted laparoscopic prostatectomy (RALP) were questioned about the sexual function information that they had received preoperatively. Patients were questioned about erectile function (EF), postoperative ejaculatory status, orgasm, and postoperative penile morphology changes. Statistical analyses were performed to assess for differences between patients who underwent open RP vs RALP. Results In all, 336 consecutive patients (from nine surgeons) with a mean (SD) age of 64 (11) years had the survey instrument administered (216 underwent open RP and 120 underwent RALP). There were no significant differences in patient age or comorbidity profiles between the two groups. Only 38% of men had an accurate recollection of their nerve‐sparing status. The mean (SD) elapsed time after RP at the time of postoperative assessment was 3 (2) months. RALP patients expected a shorter EF recovery time (6 vs 12 months, P = 0.02), a higher likelihood of recovery back to baseline EF (75% vs 50%, P = 0.01), and a lower potential need for intracavernosal injection therapy (4% vs 20%, P = 0.01). Almost half of all patients were unaware that they were rendered anejaculatory by their surgery. None of the RALP patients and only 10% of open RP patients recalled being informed of the potential for penile length loss (P < 0.01) and none were aware of the association between RP and Peyronie's disease. Conclusions Patients who have undergone RP have largely unrealistic expectations about their postoperative sexual function.
      PubDate: 2016-01-17T22:47:57.290085-05:
      DOI: 10.1111/bju.13398
  • Prevalence of the HOXB13 G84E mutation in Danish men undergoing radical
           prostatectomy and its correlations with prostate cancer risk and
    • First page: 646
      Abstract: Objectives To determine the prevalence of the HOXB13 G84E mutation (rs138213197) in Danish men with or without prostate cancer (PCa) and to investigate possible correlations between HOXB13 mutation status and clinicopathological characteristics associated with tumour aggressiveness. Materials and Methods We conducted a case–control study including 995 men with PCa (cases) who underwent radical prostatectomy (RP) between 1997 and 2011 at the Department of Urology, Aarhus University Hospital, Denmark. As controls, we used 1622 healthy men with a normal prostate specific antigen (PSA) level. Results The HOXB13 G84E mutation was identified in 0.49% of controls and in 2.51% of PCa cases. The mutation was associated with a 5.12‐fold increased relative risk (RR) of PCa (95% confidence interval [CI] 2.26–13.38; P = 13 × 10−6). Furthermore, carriers of the risk allele were significantly more likely to have a higher PSA level at diagnosis (mean PSA 19.9 vs 13.6 ng/mL; P = 0.032), a pathological Gleason score ≥7 (83.3 vs 60.9%; P = 0.032), and positive surgical margins (56.0 vs 28.5%; P = 0.006) than non‐carriers. Risk allele carriers were also more likely to have aggressive disease (54.2 vs 28.6%; P = 0.011), as defined by a preoperative PSA ≥20 ng/mL, pathological Gleason score ≥ (4+3) and/or presence of regional/distant disease. At a mean follow‐up of 7 months, we found no significant association between HOXB13 mutation status and biochemical recurrence in this cohort of men who underwent RP. Conclusions This is the first study to investigate the HOXB13 G84E mutation in Danish men. The mutation was detected in 0.49% of controls and in 2.51% of cases, and was associated with 5.12‐fold increased RR of being diagnosed with PCa. In our RP cohort, HOXB13 mutation carriers were more likely to develop aggressive PCa. Further studies are needed to assess the potential of HOXB13 for future targeted screening approaches.
      PubDate: 2016-02-12T02:10:47.668589-05:
      DOI: 10.1111/bju.13416
  • Attitudes and knowledge of urethral catheters: a targeted educational
    • Authors: Andrew Cohen; Charles Nottingham, Vignesh Packiam, Nora Jaskowiak, Mohan Gundeti
      First page: 654
      Abstract: Objective To assess the training of medical students and their confidence in urethral catheter placement, given growing evidence of unnecessary urology consults and iatrogenic injury. Subjects and Methods A third‐year medical school class was queried about their attitudes and knowledge of catheter placement before and after the Clinical Biennium. The Clinical Biennium introduces hands‐on skills prior to clinical clerkships. Urethral catheterisation 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 the same and opposite gender. Factual questions were posed about proper insertion and malfunctioning catheters. Results In all, 92 students participated in the initial survey, 41% female and 59% male, and 87% of the 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 a desire to pursue urology vs other specialties, or procedural fields compared with non‐procedural fields. Prior independent learning was reported by 38% of students and was a predictor for increased confidence across all domains (P < 0.05). In all, 16.7% of students initially identified proper male urethral insertion distance, which improved to 95.6% after the session. Student interest in urology modestly increased after the educational session (P = 0.028). At 3–6 months follow‐up, students had performed a median (interquartile range) of 4 (2–7) urethral catheter placements, and 74.2% of students rated training useful or extremely useful. Indeed, 54.8% desired more instruction. Knowledge assessment indicated that 93% of students retained comprehension of proper male urethral insertion distance. Clinical Foley training rarely contradicted instruction from the Clinical Biennium (6.5%). At all time‐points, medical student knowledge for troubleshooting catheters was low. Conclusions Medical students strive for high confidence in urethral catheter placement. Prior targeted education improves confidence and knowledge. Together with clinical experience, these effects are durable up to 6 months.
      PubDate: 2016-05-18T02:41:01.612208-05:
      DOI: 10.1111/bju.13506
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