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This image is reproduced in the article by Nguyen et al. BJUI 2013; 112: E243–E249.
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In this international multi-institutional study, Park et al. [1] have retrospectively collected and analysed data about 101 patients who underwent laparoendoscopic single-site (LESS) nephroureterectomy (NU) for upper urinary tract (UUT) urothelial carcinoma.
Nowadays, NU represents the standard of care for the surgical treatment of UUT urothelial carcinoma in the majority of patients [2]. Outcomes of such an intervention are strongly improved when lymph node dissection (LND) is performed according to a well-defined template [3].
In recent years, laparoscopy has become an important new approach to reduce the invasiveness of the surgical treatment of UUT urothelial carcinoma. In a multicentre Italian study Porpiglia et al. [4] showed that laparoscopic NU with open ureterectomy was a feasible and safe technique. Oncological results seemed to be similar to those of the traditional open approach, but the laparoscopic approach still has some disadvantages. First, patients who undergo a laparoscopic procedure receive LND with lower frequency. Moreover, the template during a laparoscopic procedure is rarely respected and the number of lymph nodes removed is often suboptimal [3]. Second, there is no consensus in the literature about the pathological stages that could potentially benefit from the bladder-cuff excision step of this procedure [5]. Bladder-cuff excision omission does not seem to undermine survival in patients with low-stage (pT1-2) disease, nevertheless confirmatory recurrence data are required before a NU without bladder-cuff excision may be considered as an option for this patient category.
The present paper shows that advances in surgical technology are being made, but it also underlines the fact that the above-mentioned disadvantages of NU are still under discussion, and these disadvantages are expanded when introducing a newer and challenging technique such as the LESS approach.
In the present study, different devices and instruments were used. Furthermore, the rate of LND reported was very low (27%), as the number of lymph nodes removed (approximately five). LND was often ‘formally’ performed, and no specific template was reported to be used. Bladder-cuff excision was not performed in 20% of cases and, when performed, the technique used was not clearly defined. With regard to oncological efficacy, the recurrence rate of 22% at 11 months is not sufficient to clarify if the LESS approach is oncologically effective [6].
In summary, there are evident limitations to the present paper; some are methodological, such as its retrospective nature and the non-homogeneous datasheets used to collect data, and some are technical and oncological. These limitations are justified by the fact that the technique is in its embryonic stages. Nevertheless, the authors deserve praise for having collected such a large number of cases for their study on LESS NU. Their paper underlines the fact that this technique is feasible and safe, and each surgeon who contributed by insisting on such a challenging and novel approach to NU should be congratulated for their efforts.
Now that the feasibility of the LESS NU technique has been demonstrated, the authors have the task of clarifying whether introducing a LESS approach would or would not compromise oncological outcomes. In any case, it is recommended that surgical oncological principles be respected when a new technique is introduced, especially when dealing with a high-risk cell-seeding tumour such as urothelial carcinoma.
Francesco Porpiglia and Riccardo Bertolo
Department of Clinical and Biological Sciences, San Luigi Hospital, Division of Urology, University of Turin, Orbassano-Turin, Italy
At the American Urological Association meeting in San Antonio in May 2005, I was introduced to a four engineers from a small start up company called NC2 (New Company 2). It had at that time been recently spun off from the medical device incubator company Exploramed. They had no product and not even a prototype of a product that could possibly be used in humans but what they did have was a passion to make a difference, incredible ideas and a laptop computer.
They had thought about the failings of existing mechanical treatments for LUTS/ BPH and the first that comes to your mind is prostatic stents. No stent conforms perfectly to the shape of the prostatic urethra and there were the issues of encrustation of any elements of stent material that were exposed to the urine. Rather than throw the baby out with the bathwater, they harnessed what was good about stents, which was the potentially immediate effects they could have on urinary function without associated destruction of tissue and that perhaps tailoring the radial expansion to just a few critical points rather than the entire length of the prostatic urethra could do the trick.
The original idea was that some sort of metallic disc could be placed outside the prostate capsule and one on the urethral side and between them, a non absorbable suture could be placed under tension and therefore draw open the prostatic urethra and defined sites. How these engineers were to find a way of designing a delivery tool to do this had me a little skeptical at first but there seemed to be no doubt in their minds, even thought they had not yet worked it out, were going to find a way. Their confidence, intellect and enthusiasm was infectious and you just felt like you wanted to be a part of this project. It so turned out that the metallic discs would be replaced by linear metallic tabs which logically make for easier delivery.
So why involve Australians? It is difficult to keep things under the radar and one way of doing so is to take the idea where it is less likely to be visible. Additionally, the data needed to be trustworthy and in a place where strong ethic committee governance structures exist. We make no illusion that for once, being Australian, gave us a clinical research opportunity from a company based in the US that would rarely be directed our way.
My Australian colleague, Dr Peter Chin was also brought in on the project. Over the next few months, we did not hear anything but there was then an urgent call that ‘California was the place we ought to be’ so we literally dropped everything and headed over to Silicon Valley where we had the opportunity to use the first prototype of the device on human cadavers. Whilst our travel costs were covered by NC2, we received no payment for our time spent during these exercises but remuneration was the last thing on our minds given the exciting path that the idea could potentially take. Simultaneously, animal studies were being conducted and these demonstrated that the internal metallic tabs of the prosthesis would become covered by urothelium and in combination with the cadaveric work, provided a convincing argument to move forward with human clinical trials.
Putting on a brave face doing the first human Urolift case at Westmead Hospital in Sydney in December 2005
By December 2005, we were ready to conduct the first human trials. We measured everything that could possibly move and it probably took close to 2 hours to perform the first case. The initial prototype device used looked like it was literally built in somebody’s garage workshop but it was functional and confirmed proof in principle that a transurethral delivery system could deploy metallic tabs on the capsular side of the prostate and within the urethra that was connected by a tensioned suture. Through this, it created mechanical alteration to the anatomy of the prostatic urethra with positive influence on lower urinary tract symptoms. From here, multiple clinical trials have been performed by the company that became known as Neotract Inc and as of 13 September 2013, the device received FDA approval.
It is enormous privilege to have played a role in product development from inception of an idea through to FDA approval. These opportunities are rare and whilst healthy skepticism and caution should be applied to all ideas presented to you, if you are offered such an opportunity to take a side project, it could be a rewarding diversion from your daily clinical practice. Financially, you will never recoup your time investment but the rewards of making a difference is priceless.
Shared passion for a project can go a long way. This experience emphasizes the value of engineers interacting with clinicians to achieve a desired outcome and there is certainly room for of such interactions. Opportunities to embrace these relationships are out there and perhaps a good place to start is to become active in the Engineering and Urology Society which as a section of the Endourological Society meets each year at the AUA Annual Meeting.
Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo
Disclosure: Henry Woo has formerly been an investigator and advisor to Neotract Inc. He holds a small stock investment in the company.
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Being an Irishman, and enthusiastic rugby supporter, I, like many other rugby fans, was much vexed when our Irish rugby hero, Brian O’Driscoll, was dropped for the deciding Test for the British and Irish Lions versus Australia this summer. This vexation was due somewhat to national pride, but more importantly, because he is one of my sporting heroes. This outpouring of emotion on the demotion of someone I’ve never met led me to contemplate the nature of heroism and heroes, how they affect us, and specifically how heroes can have a positive impact on urologists in this day and age of constant cynicism towards the noble deeds of others.
Heroism is defined as conduct as exhibited in fulfilling a high purpose or attaining a noble end. To this end, how does my rugby hero qualify? Is it his display of innate skills that thrill the crowd? Is it his professional attitude to the institution of his sport/profession? Is it his ability to overcome adversity for the good of his team? (These are all attributes I see in my Urological heroes.) Personally, I think back to moments where I realised that he had done things that I couldn’t even imagine being able to do, and just marvel at them. Passing the ball to himself and ghosting past the opposition, scoring a length of the field try and being physically ill afterwards due to a pre-existing virus, being listed as ‘likely to play’ for the following week with a personal injury list of ‘concussion, torn hamstring and lacerated ear’. These are levels of physical and athletic prowess unattainable by most people.
But what of others that I would class as heroes? It is 50 years this June since the late John F. Kennedy made his famous speech in Berlin, immortalised by the phrase “Ich bin ein Berliner’. However, his greatest segment is when he lists some of the positives that people were attributing to Communism at the time, and extolling his own personal opposition with the repeated statement ‘Let them come to Berlin!’ Watching the reaction of a group of Berliners to this speech 40 years after its occurrence, seeing them moved to tears by his reiteration of the support of the free world to the citizens of Berlin, this alone is enough to convince me of the heroism of this amazing, somewhat flawed, ever impressive man.
Heroism can also be displayed by people using their professional experience to reach extraordinary outcomes in the face of enormous adversity. Captain Chesley ‘Sully’ Sullenberg, who, after a complete engine failure on his commercial jet, in the space of 180 seconds, managed to control and ditch his plane on the Hudson River in New York, saving 155 souls. His wife, on being told that her husband had landed a multi-ton commercial jet in a river, with no harm to anyone, apparently replied laconically “Oh that sounds like Sully, alright”.
But how does this relate to urologists? It is my personal belief that the ‘heroes’ we have in society today are not fit for purpose, vacuous celebrities of little consequence in general, and that we would all gain much by having a number of personal and professional heroes that we can use as an example when adversity, conflict, or difficult decisions face us as surgeons. Surgeons should, and often do, aim to attain a noble end. I have many heroes in Urology in particular, and often use their example, and sage-like advice in times of difficulty,
It is extremely easy to live life these days in a manner that loses sight of the wonder and awe with which we held medicine when young. It is easy to live life in a manner where much of it seems jaded and worn. It is easy to believe that there are things we cannot do, goals we cannot reach, achievements we cannot achieve. In these situations, having a hero, whose deeds seem somehow beyond what the rest of us can do, can give us a guide, an example to strive to emulate, attempt to equal, maybe even to surpass. It is this aspect of heroism which can be utilised as something to be aspired to, for the betterment of all.
On a final note, I am often astounded by the heroism of my patients. For these people to be able to face ill health, their own frailties and mortality and put their trust in us as surgeons, especially if we are recommending a new or unique form of treatment, is to display a level of trust that definitely puts them in the pantheon of heroes for me. I believe we owe it to them to remain interested, invigorated and willing to sacrifice ourselves to emulate our heroes, for their benefit. Heroes are great, everyone should have one!
David Bouchier-Hayes is Consultant Urologist and Robotic Surgeon Honoray Clinical Lecturer at the Galway Clinic, Doughiska, Co. Galway, Ireland. Follow him on Twitter @dbh44
In the developing immune system, all T cells are positively selected in the neonatal thymus for the ability to recognize self-antigens, the major histocompatibility complex (MHC) proteins. Thus, the mature T-cell repertoire is trained to ‘see’ foreign pathogens ‘complexed’ with those self-antigens (‘MHC-presentation’). Fundamentally, this requirement predisposes mammalian systems to the development of autoimmune diseases, as all T cells are self-reactive. That such diseases are the exception rather than the rule is attributable to a small population (∼2–5%) of circulating T cells, termed ‘regulatory T cells’ (Tregs), that suppress the activation and function of many other immune cells. The fine balance between Tregs and other pro-inflammatory cells is essential for maintaining self-tolerance while allowing immunological reactivity against danger signals such as foreign antigens (mostly pathogens) and malignant cells. Many pathogens co-evolving alongside the mammalian immune system have learned to ‘hijack’ this balance to propagate disease or to inhibit their own clearance, notably Leishmaniasis, malaria, tuberculosis, HIV, hepatitis C virus and Helicobacter pylori. In these scenarios, an excess of Tregs induced by the pathogens prevents their clearance and establishes infective chronicity.
Likewise, in malignant diseases, such as pancreatic and ovarian cancer, an excess of Tregs is thought to contribute to failure of the immune system to clear neoplastic cells. Whether the tumour environment appropriates the regulatory function of Tregs to propagate its own survival in a manner akin to infectious agents, or whether Tregs infiltrate larger tumours in which there is more chronic inflammation is unclear. Nevertheless, a correlation between higher Treg numbers and poorer outcomes is a common feature of malignancies. In this issue of the BJUI Polimeno et al. add evidence to the debate over whether Treg numbers in RCC are associated with worse outcomes. While previous publications both support (Cancer Immunol Immunother 2007, BJU Int 2009) and refute (Clin Cancer Res 2007) this assertion, the data presented by Polimeno et al. identify not only increased circulating Treg numbers in patients with RCC but also find an association betweenTreg numbers, especially those that express the naïve T-cell marker CD45RA, and both larger tumour load and worse prognosis. In the same dataset, as expected, the authors also find that a shorter disease-free survival was evident in patients with lower numbers of tumoricidal natural killer cells. In the serum, patients with RCC had higher concentrations of soluble factors involved in cell growth and movement, such as epidermal growth factor, hepatocyte growth factor, vascular endothelial growth factor and interferon γ-induced protein 10 (also known as CXCL10), and markers of active inflammation, such as interleukins 6 and 8.
These observations suggest several broad possibilities: (i) that the ‘Tregs’ identified in the tumour environment and circulation are not Tregs but are in fact other activated T cells that temporarily express the same surface markers as bona fide Tregs; (ii) that Tregs in the context of RCC are unable to control tumour-associated inflammation; (iii) that Tregs contribute to tumour survival by inhibiting clearance of neoplasms by other immune cells, resulting in chronic inflammation; and/or (iv) that Tregs are actively contributing to the inflammation by converting to pro-inflammatory phenotypes, as has been demonstrated by several groups. These possibilities can be differentiated by isolating Tregs from the tumour environment or local draining lymph nodes and testing their functional characteristics in vitro; however, the fact that CD45RA+ Tregs were independently associated with worse outcomes makes (i) and (ii) less likely, as such cells are less likely to be recently activated and are inherently less plastic than other populations of Tregs.
In our opinion, the clinical value of the data presented in this paper and those of others, even if the underlying biology is poorly understood, should next be determined in a prospective study to see whether the immunological ‘fingerprint’ in peripheral blood can correctly identify those patients who are more likely to do poorly, targeting them for closer monitoring and/or more aggressive therapy.
Behdad Afzali and Giovanna Lombardi
Medical Research Council Centre for Transplantation, King’s College London, King’s Health Partners, Guy’s Hospital, and National Institute for Health Research Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, Guy’s Hospital, London, UK
When it comes to live surgery meetings, one of the biggest and best of them all is the EAU Robotic Urology Section (ERUS) Congress (formerly the European Robotic Urology Symposium). The 10th edition of ERUS took place in Stockholm this week and continued the tradition of spectacular live robotic assisted surgery, along with scientific sessions dealing with issues around robotic assisted surgery. Following discussions with the EAU over the past two years, ERUS has now become an official section of the main EAU Organisation and future scientific and educational activity will be co-ordinated under that esteemed banner. In his welcoming address at this weeks meeting, EAU Secretary General and proud Swede Per-Anders Abrahamsson, warmly welcomed ERUS into the EAU family. He also highlighted the mission statement of ERUS, “to support science and education in the field of robotic urology”.
Over 750 delegates gathered from around the world (including a healthy delegation from Australia, South America and the USA), giving this meeting a truly global footprint. The programme featured 12 live surgical procedures performed by some of the world’s leading robotic surgeons and broadcast in full 3-D from Karolinska Hospital.
This meeting has showcased many advances in roboticsurgery over the past 10 years and this year was no exception. The audience seemed most interested in extended public lymph node dissection during radical cystectomy and prostatectomy, as well as intra-corporeal urinary diversion and complex partial nephrectomy. This year’s starring surgeons included Alex Mottrie, Peter Wiklund, Magnus Annerstedt, Geoff Coughlin, Hubert John, Aldo Bocciardi, Jean Palou, Carl Wijburg, Craig Rogers, Jim Porter, Tim Wilson, Vip Patel and Abi Hosseini. An outstanding line-up of surgeons from all over the world.
Of note, this Section has led the development of ethical guidelines around the conduct of live surgery and these have been fully endorsed by the EAU. We have previously blogged about this issue and I have blogged about my own experience of doing live surgery at ERUS 2012 in London. As part of the live surgery ethical governance, Convener of ERUS 2012, Ben Challacombe (London), presented an update on the outcome of all patients who underwent live surgery as part of last years meeting.
The main scientific meeting was preceded by the Junior ERUS Section, the Nursing Course on Robotics, and five master classes led by experts and dealing with various aspects of robotic assisted surgery. The Junior ERUS Prize was awarded to Khan et al who presented a poster on behalf of the International Robotic Curriculum Group entitled, “Towards a Standardised Training Curriculum in Robotic Surgery”. There were also a number of parallel meetings dealing with education and scientific activity within ERUS/EAU, in particular, the development of structured robotic training and a robotic surgery curriculum across Europe and beyond. The BJUI Editor in Chief Prokar Dasgupta, a well-known robotic surgery innovator and also an expert in simulation and education, is playing an active role coordinating development of this curriculum. European Urology Editor in Chief Jim Catto, was also present at ERUS 2013 and delivered a podium presentation outlining some of the exciting changes which the Platinum Journal will undertake once he takes over in January 2014. What is clear is that robotic surgery is an important part of the content for both of these leading journals.
Of course, this meeting has a particular reputation as being a friendly and sociable event (a point repeatedly mentioned by many of the Intercontinental visitors). The local organising committee pulled out all the stops with the official social events by hosting the welcome reception at the Stockholm City Hall, home of the famous Nobel Prize banquet each year. The gala dinner was in the spectacular Vasa Museum, surely one of the world’s most spectacular maritime museums.
We were treated to a tour of this spectacular, fully intact 17th century warship, followed by dinner in the shadow of this huge exhibit, notorious for capsising in Stockholm harbor only 15 minutes into her maiden voyage.
As we have seen at all major urology meetings this year, social media played a prominent role in expanding the reach of the meeting and in enabling engagement from within the audience and from around the world. The conference organisers placed a Twitter feed on the panellists monitors so that questions could be directed via Twitter to the expert panels and to the operating rooms.
As if the spectacular multiple source 3-D display was not providing enough content, social media guru Carl Wijburg was busy tweeting “backstage” photos from Karolinska as he waited to perform a meticulous extended pelvic lymph node dissection.
The final data from Symplur showed just how enthusiastically delegates from all over engaged with the meeting through Twitter.
Congratulations go to the organisers and scientific committee of #ERUS13 led by Alex Mottrie (Belgium), Peter Wiklund (Stockholm) and Magnus Annerstedt (Copenhagen) who did an outstanding job putting on this complex congress.
We are already looking forward to ERUS 2014 which takes place in beautiful Amsterdam from 17- 19th September 2014, led by Chair of the Local Organising Committee, Henk van der Poel. A must-attend for anyone interested in robotic surgery.
Declan Murphy BJUI Associate Editor
Follow Declan on Twitter @declangmurphy
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The September #urojc International Urology Journal Club discussion on twitter was based on the paper “Long-Term Survival of Participants in the Prostate Cancer Prevention Trial” published in the New England Journal of Medicine a few weeks earlier.
In 2003, the Prostate Cancer Prevention Trial (PCPT) proved what it set out to do. It significantly reduced the risk of PCa. Unfortunately, the champagne was never even taken off ice, as finasteride was also associated with an increased risk of high-grade prostate cancer. In June 2011, US FDA ordered the drug’s warning label to be updated to state that finasteride may increase the risk of high grade prostate cancer. As a primary prevention drug for PCa, despite many published, favorable subgroup analyses, finasteride was quite flaccid in the eyes of many urologists.
Now, ten years after the PCPT was published and with up to 18 years of follow-up, would these long-term results be the catalyst to force an FDA backflip? Or would the specter of erectile dysfunction rise? Amongst the first tweets that were fired (no prizes to guess who it was)
To summarise, this post hoc analysis – that wasn’t pre-specified in the original protocol – analysed rates of survival among all original PCPT study participants including those with prostate cancer. Prostate cancer incidence amongst PCPT candidates was collected for an additional year after the original report and the Social Security Death Index was searched to assess survival status until 31st October 2011.
In all 18,880 men, PCa was diagnosed in 10.5% of the finasteride group and 14.9% of the placebo group (RR in finasteride group, 0.70; 95% CI, 0.65 to 0.76; P<0.001). Furthermore, 333 (3.5%) in the finasteride group and 286 (3.0%) in the placebo group had high-grade cancer (GS, 7 – 10, RR, 1.17; 95% CI, 1.00 to 1.37; P=0.05). Fifteen-year survival rates of 78.0% (finasteride) and 78.2%, (control) were reported in the men who died. Unadjusted hazard ratio for death in the finasteride group was not significant. Ten-year survival rates were 83.0% (finasteride) 80.9% (placebo) with low-grade PCa and 73.0% and 73.6%, respectively, with high-grade prostate cancer.
The authors as well as the #urojc community were quick to identify limitations.
Indeed, since information regarding the mode of death for patients who passed away was unavailable, PCa specific mortality could not be reported by this study. In amongst the discussion regarding limitations, it was important to see twitter etiquette observed.
There was some discussion on whether high grade “finasteride” prostate cancer was morphologically identical to “placebo” prostate cancer or different?
But at the end of the day, it doesn’t matter how it is discussed, packaged or assembled…
In an underpowered study, not designed to look at PCa-specific mortality, there was always going to be conjecture as to the benefit of reducing low grade PCa by 30% (in an era of increased active surveillance) whilst giving 1 in every 200 men offered finasteride high grade PCa.
Erectile dysfunction was an ever present factor during our discussion, although was generally thought of as #firstworldproblems
At times, when drawing conclusions, our intellectual, verbatim-driven minds give way to pictorial clarity; in other words a picture tells a thousand words. I still wonder how many a tweet is worth… In my very humble opinion, my conclusions are
1) 5 ARIs decrease low grade PCa, but low grade PCa doesn’t necessarily equal death, so…
2) Primary prevention for PCa would need to be robust, 5ARIs are too far from the mark
3) I thought appropriately chosen patient with bothersome LUTS, a large prostate with elevated PSA (proved to be cancer free or low volume GS 6) should go green (I can already feel the holmium lasers, microwave emitters and diode beams aimed behind my head, but that is a conversation for another time…)
The king summed it up well I think,
This month’s prize has been generously donated by Urological Society of Australia and New Zealand, one full registration to USANZ ASM 2014 in Brisbane! There was a clear winner who was novel in tweeting an image that said it all.
Congratulations to Dr Todd Morgan!
A warm thank you is extended to all who participated in this month’s #urojc discussion. All of you are encouraged to participate in next month’s discussion starting on 4th-5th October depending on your time zone.
Analytics for for this month’s discussion:
Dr George Koufogiannis is an Australian Urology Trainee, currently based at Port Macquarie Hospital. @DrVasano78 Vasano = torment, 78 = 1978, the year I began to torment my mother, who gave me the nickname.
Urological oncology is increasingly multi-disciplinary, and hence competitive for high impact thought leadership. Innovation leading to paradigm changes may come from a number of different ideas and sources. Effective leadership in our specialty certainly requires technical innovations in surgical treatments, but also pivotal roles in improving the process of diagnosis, staging, patient counselling, multi-modal therapy, and ultimately evidence-based clinical guidelines. The ultimate end-result of innovation is a peer reviewed publication, and at the BJUI we wish to bring you nothing but the highest quality.
Our daily lives are increasingly busy with our varying mixtures of clinical work, teaching, administration, and research. How much time do we have to read a surgical journal? It is an important part of our learning, but we must be efficient to squeeze it into a busy day. Keeping this in mind, the Editorial Board is more selective than ever in the papers that make it into the BJUI. Each paper we accept needs to represent something valuable to the reader and to our science, such as a technical innovation, large study of a new method to fix an unmet need, multi-institutional validation trial, or updated guideline. For this to work, we need fair and efficient peer reviewers, and high quality submissions.
In this month’s BJUI, we see encouraging work from multiple talented authorship groups who address a plethora of unmet needs. These papers show the diversity of impact the Editorial team is looking for in BJUI urological oncology submissions.
Prostate cancer, of course, is a common topic for new submissions and subsequent citations. In the field of localised prostate cancer and PSA screening, the recent U.S. Preventive Services Task Force (USPSTF) report was critical of our diagnostic practice results in terms of biopsy related complications and, of course, negative (a.k.a. unnecessary, a term we should drop) biopsies. I must confess that I am still stuck in the tradition of the PSA/DRE as the key driver of my recommendation for a biopsy, and several informal ‘raise your hand’ polls at meetings have produced little movement when asked if anyone has adopted newer calculators that incorporate TRUS volume. Why not change? The numbers certainly seem reasonable: an area under the curve (AUC) of 0.71 for DRE/PSA and 0.77 for the risk calculator. You can even make a crude DRE-volume estimate and improve your odds – AUC of 0.73 without and 0.77 with DRE-volume. If that sounds of interest, then perhaps the study by Carlsson et al. in this issue may interest you with their biomarker panel of kallikreins that can do the same work as the combined clinical efforts and reach AUCs of 0.76 alone, or 0.792 if you still want to add the DRE and TRUS volume. I agree with the authors, that this is perhaps a simpler model, which may allow the physician and patient some time to have a look at their risk of a positive biopsy and make a decision, rather than the idea of the last minute TRUS volume that is supposed to put the brakes on a biopsy at a certain size. With further refinement, we can all learn new thresholds for biopsy that are better selected, and in the future should always be calculated as overall cancers detected/missed and high-grade cancers detected/missed.
In addition, the USPSTF criticised the toxicity of a biopsy, and drug-resistant sepsis is an increasing problem. Symons et al. present an instructive series of transperineal biopsies and results, and they seem to have solved the sepsis problem (0.2%), but must weigh the added cost of anaesthesia, physician time, and no obvious difference in bleeding/other minor complications. I am increasingly interested in re-utilising this technique, which previously was only for third-line saturation biopsies. If you are also convinced, Kuru et al. present a tour-de-force presentation of transperineal technique, terminology, and data collection for a multi-centre collaboration.
Finally, in a must-read special article, Carter expands upon the recent AUA guidelines on PSA screening that were intensely debated, especially the recommendations against routine screening in men aged <55 years. Guidelines are an interesting area of study, and can vary in outcome based upon who is on them and what methodology/objectives are selected. If the guideline is meant to be best clinical practice, than the personnel can certainly be influential. However, if the guideline is meant to emphasise evidence-based recommendations, then in theory, any panel of experts will arrive at a similar place. This is the essential message from Carter, that the revised guidelines are meant to reflect the evidence, and currently we do not have level 1 evidence that involved screening men aged <55 years.
Closing this month in ‘Urological Oncology’, Cindolo et al. report an accuracy/generalizability study of the Karakiewicz nomograms for cancer-specific survival with RCC. These articles are, of course, largely statistical exercises, but very necessary, as we define populations suitable for surgery only vs those in need of neoadjuvant/adjuvant inclusion. Wong et al. conclude the month with an innovative report on office-based laser ablation of non-muscle-invasive bladder cancer using local anaesthesia, mostly in an elderly population. The study protocol allowed photodynamic diagnosis, and includes a cost analysis. The results certainly support continued use in this population where we commonly wish to avoid the morbidity of repeat general anaesthetics.
John W. Davis, MD, FACS
Associate Editor, BJUI
Original publication of this editorial can be found at: doi: 10.1111/bju.12380. BJUI 2013; 112: 531–532.
