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Background: Upper urinary tract urothelial carcinoma (UTUC) is often locally advanced at initial diagnosis and is associated with high recurrence and mortality rates after radical nephroureterectomy (RNU). Adjuvant platinum-based chemotherapy has shown a recurrence-free survival benefit in a randomised phase III trial, while neoadjuvant treatment seems promising in retrospective series. On the contrary, little is known about the role of perioperative immunotherapy and its combination with chemotherapy for UTUC patients, although initial positive results have been published for muscle-invasive bladder cancer. Study design and endpoints: Against this backdrop, we are running a multi-centre single-arm phase 2 trial of neoadjuvant Durvalumab, a monoclonal antibody targeting programmed cell death ligand 1, combined with Gemcitabine and Cisplatin or Carboplatin for high-risk UTUC patients. The primary outcome is pathological complete response rate at RNU. Secondary endpoints include the partial pathological response rate, safety, as well as disease-free and overall survival. A biomarker analysis is also planned. Patients and interventions: Included patients must have a good performance status and harbour a non-metastatic UTUC, considered at high risk of progression, defined as either biopsy-proven high-grade disease or invasive features at imaging with or, more recently, without high-grade cytology at the multidisciplinary team discretion, as specified in the latest amendment. Enrolled patients receive 3 cycles of neoadjuvant immuno-chemotherapy before RNU, and the standard of care thereafter. The trial is registered as NCT04617756 and is supervised by an independent data monitoring committee. [ABSTRACT FROM AUTHOR]

The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial carcinoma (UTUC) has updated the guidelines to aid clinicians in evidence-based management of UTUC. To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. The recommendations provided in these guidelines are based on a review of the literature via a systematic search of the PubMed, Ovid, EMBASE, and Cochrane databases. Data were searched using the following keywords: urinary tract cancer, urothelial carcinomas, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, (neo)adjuvant treatment, instillation, recurrence, risk factors, metastatic, immunotherapy, and survival. The results were assessed by a panel of experts. Even though data are accruing, for many areas there is still insufficient high-level evidence to provide strong recommendations. Patient stratification on the basis of histology and clinical examination (including imaging) and assessment of patients at risk of Lynch syndrome will aid management. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk UTUC and two functional kidneys. In particular, for patients with high-risk or metastatic UTUC, new treatment options have become available. In high-risk UTUC, platinum-based chemotherapy after radical nephroureterectomy, and adjuvant nivolumab for unfit or patients who decline chemotherapy, are options. For metastatic disease, gemcitabine/carboplatin chemotherapy is recommended as first-line treatment for cisplatin-ineligible patients. Patients with PD-1/PD-L1–positive tumours should be offered a checkpoint inhibitor (pembrolizumab or atezolizumab). These guidelines contain information on the management of individual patients according to the current best evidence. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen according to the risk stratification of these tumours. Cancer of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, timely and appropriate diagnosis is most important. A number of known risk factors exist. [ABSTRACT FROM AUTHOR]

We evaluate the predictive and prognostic value of insulin-like growth factor-I (IGF-1), IGF binding protein-2 (IGFBP-2) and -3 (IGFBP-3) in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). This is a retrospective analysis of a multi-institutional database comprising 753 patients who underwent RNU for UTUC and had a preoperative plasma available. Logistic and Cox regression analyses were performed. The discriminative ability and clinical utility of the models was calculated using the lasso regression test, area under receiver operating characteristics curves, C-index, and decision curve analysis (DCA). Lower preoperative plasma levels of IGFBP-2 and -3 independently correlated with increased risks of lymph node metastasis, pT3/4 disease, nonorgan confined disease, and worse recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) (all P ≤.004). The addition of both IGFBP-2 and -3 to a postoperative multivariable model, that included standard clinicopathologic characteristics, improved the model's concordance index by 10%, 9%, and 8% for RFS, CSS, and OS, respectively. On DCA, addition of both IGFBP-2 and -3 to base models improved their performance for RFS, CSS, and OS by a statistically and clinically significant margin. Plasma IGF-1 was not associated with any of outcomes. We confirmed that a lower plasma levels of IGFBP-2 and -3 both are independent and clinically significant predictors of adverse pathological features and survival outcomes in UTUC patients treated with RNU. These findings might help guide the clinical decision-making regarding perioperative systemic therapy and follow-up scheduling. The predictive value of insulin-like growth factor-I (IGF-1) and its binding proteins were assessed in 735 patients treated with RNU for UTUC. Lower plasma levels of IGFBP-2 and -3 are significant predictors of adverse pathological features and survival outcomes in UTUC patients treated with RNU and help guide the clinical decision-making regarding perioperative systemic therapy and follow-up scheduling. [ABSTRACT FROM AUTHOR]

Objective: To assess awareness of bladder cancer (BCa) in France. Methods: The French nationwide observational survey EDIFICE 6 was conducted online (26 June–28 July 2017) in 12,046 individuals (age, 18–69 years). The present analysis focuses on laypersons' knowledge of the severity and frequency of BCa, signs and symptoms, associated risk factors and screening tests. Quantitative data were expressed as means and standard deviation, and categorical data as percentages. Results: Analyses were conducted on 11,313 questionnaires. Among the top five acknowledged risk factors for BCa, tobacco was ranked as having the second lowest impact (5.9/10 [2.5]). Only 28% of the study population were aware that active tobacco smoking is a major risk factor for BCa (rating ≥8/10); 61% of the study population was unaware of the existence of any signs or symptoms of BCa, and 69% was not able to cite any of the most widely used diagnostic tests. Conclusions: We found that the French population has a poor knowledge of BCa risk factors, early signs and diagnostic tests. Effective prevention of BCa requires dissemination of clear information and prevention messages to the lay population, focusing particularly on tobacco consumption and early signs of the disease. [ABSTRACT FROM AUTHOR]

The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer, urothelial carcinomas, upper urinary tract carcinoma, renal pelvis, ureter, bladder cancer, chemotherapy, ureteroscopy, nephroureterectomy, neoplasm, adjuvant treatment, instillation, recurrence, risk factors, and survival. References were weighted by a panel of experts. Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification as well as for radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumour and two functional kidneys. After radical nephroureterectomy, cisplatin-based chemotherapy is indicated in locally advanced UTUC. These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist. Based on the most recent evidence, the 2020 European Association of Urology guidelines on upper urinary tract urothelial carcinoma aim to provide information on the management of individual patients according to a current standardised approach. Urologists should take the specific clinical characteristics of each patient into account when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. [ABSTRACT FROM AUTHOR]

Good-quality transurethral resection of non–muscle-invasive bladder cancer may change the course of the disease. Multiple prospective trials have confirmed the efficacy of photodynamic diagnosis in detecting tumours and thus facilitating adequate resection. [ABSTRACT FROM AUTHOR]

Purpose: To summarize current knowledge on upper urinary tract carcinoma (UTUC) regarding risk stratification, long-term results, and follow-up. Methods: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC, September 2018, Stockholm. Results: To optimize oncological outcome considering both cancer-specific survival (CSS) and overall survival (OS), it is essential to identify pre- and postoperative prognostic factors. In low-risk UTUC, kidney-sparing surgery (KSS) and radical nephroureterectomy (RNU) offer equivalent CSS, whereas RNU may result in poorer OS due to nephron loss. For more aggressive tumours, undergrading can lead to insufficient treatment. The strongest prognostic factors are tumour stage and grade. Determining grade is best achieved by ureterorenoscopy (URS) with focal samples, biopsy and cytology. Staging is more difficult but can be indirectly achieved by multiphase computed tomography urography (CTU) or tumour grade determined by cytology and histopathology. Patients treated with KSS should be monitored closely with regular follow-ups (URS and CTU). Conclusion: KSS should be offered in low-risk UTUC when feasible, whereas RNU is the treatment of choice in organ-confined high-risk UTUC. Intravesical recurrence (IVR) is common after RNU, but a single postoperative dose of mitomycin instillation decreases IVR. Endourological management has high local and bladder recurrence rates; however, its effect on CSS or overall survival OS is unclear. RNU is associated with significant risk of chronic kidney disease. Careful selection of patients and risk stratification are mandatory, and patients should be followed according to strict protocols. [ABSTRACT FROM AUTHOR]

Context The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. Objective To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. Evidence acquisition The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; ureteroscopy; nephroureterectomy; adjuvant treatment; instillation; recurrence; risk factors; and survival. References were weighted by a panel of experts. Evidence synthesis Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing number of retrospective articles in UTUC. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification, as well as for radical and conservative treatment; prognostic factors are also discussed. A single postoperative dose of intravesical mitomycin after radical nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumours and two functional kidneys. Conclusions These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. Patient summary Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis; appropriate diagnosis and management is most important. We present recommendations based on current evidence for optimal management. [ABSTRACT FROM AUTHOR]

Background: Upper tract urothelial carcinoma (UTUC) is a rare and heterogeneous disease. Several clinical and biological prognostic factors have been identified in multi-institutional collaborative works with the aim of helping decision-making in pursuit of tailored individual patient care. This review provides an overview of these existing prognostic factors and predictive tools for the management of patients with UTUC. Methods: A systematic literature search was performed using PubMed/MEDLINE, Web of Science and Scopus databases regarding articles published in English between January 2000 and November 2015 according to PRISMA guidelines. Thresholds of 100 and 300 patients were applied for studies on biomarkers and clinical studies, respectively. All the studies on predictive tools were included for analysis. Outcomes of interest were features associated with advanced-stage UTUC, disease recurrence and survival. Results: A total of 116 studies were included in this review. These large and/or multi-institutional studies have confirmed the prognostic value of standard pathological factors (i.e., tumor stage, grade and lymph node metastasis) and identified novel features such as lymphovascular invasion, tumor architecture, multifocality, concomitant CIS, variant histology and biomarker status among others. Based on these variables, several predictive tools have been developed; however, they often lack of validation. The value of these features and tools needs prospective testing. Conclusion: Efforts provided by international collaboration groups have permitted to validate established features and identify new features of biologically and clinically aggressive UTUC. Further investigation on prognostic factors and biomarkers is still needed to assess the benefit of these features and tools on clinical decision-making. [ABSTRACT FROM AUTHOR]

Context The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial cell carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. Objective To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians. Evidence acquisition The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using these keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; and survival. References were weighted by a panel of experts. Evidence synthesis Due to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing interest in UTUC. The 2009 TNM classification is recommended. Recommendations are given for diagnosis and risk stratification as well as radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Recommendations are also provided for patient follow-up after different therapeutic strategies. Conclusions These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. Patient summary Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist. [ABSTRACT FROM AUTHOR]

Objective To compare outcomes of patients with lymph node ( LN)-positive urothelial carcinoma of the bladder ( UCB) treated with or without cisplatin-based combined adjuvant chemotherapy ( AC) after radical cystectomy ( RC). Patients and Methods We retrospectively analysed 1523 patients with LN-positive UCB, who underwent RC with bilateral pelvic LN dissection. All patients had no evidence of disease after RC. AC was administered within 3 months. Competing-risks models were applied to compare UCB-related mortality. Results Of the 1523 patients, 874 (57.4%) received AC. The cumulative 1-, 2- and 5-year UCB-related mortality rates for all patients were 16%, 36% and 56%, respectively. Administration of AC was associated with an 18% relative reduction in the risk of UCB-related death (subhazard ratio 0.82, P = 0.005). The absolute reduction in mortality was 3.5% at 5 years. The positive effect of AC was detectable in patients aged ≤70 years, in women, in pT3-4 disease, and in those with a higher LN density and lymphovascular invasion. This study is limited by its retrospective and non-randomised design, selection bias, the absence of central pathological review and lack in standardisation of LN dissection and cisplatin-based protocols. Conclusion AC seems to reduce UCB-related mortality in patients with LN-positive UCB after RC. Younger patients, women and those with high-risk features such as pT3-4 disease, a higher LN density and lymphovascular invasion appear to benefit most. Appropriately powered prospective randomised trials are necessary to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective To establish whether the expression of forkhead box protein P3 ( Foxp3) provides specific diagnostic information about neurological patients with urothelial carcinoma of the bladder ( UCB). Patients and Methods UCB tissue samples from neurological patients were retrieved and compared with control samples. The expression of Foxp3 was analysed via immunohistochemistry of microarray tissue sections. The correlation between Foxp3 expression, histological parameters and tumour stage was assessed. Results Overall, 20 UCB tissue samples and 20 others without UCB from neurological patients, and 46 UCB tissue samples from non-neurological patients were analysed. The distribution of pT of UCB in the neurological patients was as follows: one low-grade pTa (5%), three high-grade pTa (15%), three pT1(15%), one pT2(5%), seven pT3(35%) and five pT4(25%). Squamous cell differentiation was seen in nine UCB samples (45%). Foxp3 expression was detected in tumour tissues, including one pTa high grade, one pT1, one pT2, five pT3 and five pT4 tumours. Foxp3 was expressed in 11/13 muscle-invasive tumours. All tumours displaying squamous cell differentiation expressed Foxp3. Foxp3 was not expressed in the pT3 tumours that displayed sarcomatoid and micropapillary properties. Among the bladder samples without UCB from neurological patients, no expression of Foxp3 was observed. Among the UCB samples from the non-neurological patients, only seven displayed squamous cell differentiation. All tumours that displayed squamous cell differentiation expressed Foxp3, including one pTa high grade, four pT3 and two pT4 tumours. Other tumours displaying urothelial differentiation did not express Foxp3. The expression of Foxp3 correlated to squamous cell differentiation in neurological ( P = 0.004) and non-neurological UCB tissue ( P < 0.001). In neurological, but not non-neurological UCB tissue, the expression of Foxp3 correlated with the muscle-invasive stage ( P = 0.022). Conclusions Elevated expression of Foxp3 appears to be a characteristic of neurological patients presenting with aggressive UCB and squamous cell differentiation. Targeting Foxp3 may represent a novel strategy to improve anti-tumour immunotherapy for UCB. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the influence of preoperative factors on the survival of patients diagnosed with upper tract urothelial carcinoma (UTUC) who underwent a radical nephroureterectomy (RNU). Methods: A multicentre retrospective study was performed on all patients with UTUC who underwent a RNU. Multiple preoperative criteria were tested as prognostic factors for cancer-specific survival (CSS) using univariate and multivariable Cox regression analyses. Results: Overall, 476 patients with a median age of 69.2 (IQR 60.8-76.5) years were included. The median follow-up was 27.8 months (IQR 10.5-49.3). At the time of diagnosis, 400 (84.1 %) patients presented with symptoms and 76 patients (15.9 %) were asymptomatic. Renal failure, altered general health, a preoperative locally advanced tumour and multifocal disease appeared to be preoperative prognostic factors for CSS ( p = 0.01, 0.03, 0.001 and 0.03, respectively) in the univariate analysis. Only renal failure ( p = 0.03), a preoperative locally advanced tumour (0.004), and multifocal locations ( p = 0.01) were confirmed as independent factors of CSS in the multivariate analysis. The independent prognosticators of definitive muscle-invasive stage and non-organ-confined disease were preoperative renal failure ( p = 0.02, 0.027, respectively), locally advanced stage ( p < 0.001, <0.001, respectively) and positive cytology ( p = 0.006, 0.003 respectively). Female gender was independent factor only for prediction of final non-organ-confined disease ( p = 0.007). The addition of these parameters in our preoperative complex model permitted the prediction of muscle-invasive or locally advanced disease in 65.3 and 67.2 % of patients, respectively. Conclusions: Patients with preoperative impaired renal function, locally advanced stage and multifocal tumours before RNU had worse survival outcomes compared to other patients. [ABSTRACT FROM AUTHOR]

Objectives To assess the accuracy of magnetic resonance imaging ( MRI)/transrectal ultrasonography ( TRUS) fusion to guide first-round biopsies in the diagnosis of localised prostate cancer ( PCa) in men with a prostate-specific antigen ( PSA) ≤10 ng/mL. Patients and Methods A prospective study was conducted on men who met the following criteria: first-round biopsy, multiparametric MRI ( mpMRI) showing a lesion with a Likert score ≥2 and a PSA <10 ng/mL. All men underwent a extended 12-core protocol plus a protocol of two or three targeted cores on the mpMRI index lesion. The UroStation™ ( Koelis, Grenoble, France) and a V10 ultrasound system with an end-fire three-dimensional TRUS transducer were used for the fusion imaging procedure. Significant PCa was defined as: at least one core with a Gleason score of 3 + 4 or 6 with a maximum cancer core length ≥4 mm. Results A total of 152 men, whose median PSA level was 6 ng/mL, were included in the study. The proportion of positive cores was significantly higher with the targeted-core protocol than with the extended 12-core protocol ( P < 0.001). The proportion of men with clinically significant PCa was higher with the targeted-core protocol than with the extended 12-core protocol ( P = 0.03). The proportion of patients having at least one positive biopsy (targeted-core protocol) was significantly different among the Likert score categories ( P < 0.001). Conclusions For the first round of biopsies, MRI/ TRUS-fusion targeted biopsies detected more men with clinically significant PCa than did standard extended 12-core biopsy alone. [ABSTRACT FROM AUTHOR]

Social media use is becoming common in medical practice. Although primarily used in this context to connect physicians, social media allows users share information, to create an online profile, to learn and keep knowledge up to date, to facilitate virtual attendance at medical conferences, and to measure impact within a field. However, shared content should be considered permanent and beyond the control of its author, and typical boundaries, such as the patient–physician interaction, become blurred, putting both parties at risk. The European Association of Urology brought together a committee of stakeholders to create guidance on the good practice and standards of use of social media. These encompass guidance about defining an online profile; managing accounts; protecting the reputations of yourself and your organization; protecting patient confidentiality; and creating honest, responsible content that reflects your standing as a physician and your membership within this profession. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to assess the use of immediate postoperative instillation of intravesical chemotherapy (IPOIC) after transurethral resection of bladder tumour (TURBT) of nonmuscle invasive bladder cancer (NMIBC) in Europe. Methods: Urologists based in five European Union nations were asked to extract information from the records of patients with NMIBC-urothelial carcinoma who received at least one TURBT. Multivariate logistic regression models were developed to determine the significant predictors of IPOIC usage. Data were weighted to control for country-to-country and other differences. Results: Overall, 324 urologists (58 France, 72 Germany, 62 Italy, 65 Spain, 67 United Kingdom) were involved; the participation rate was 55 %. Overall, 771 patients received 954 TURBTs (mean-1.2/patient), of which 413 of the TURBTs (43.3 %) were administered IPOIC . Sixty-six of the 413 IPOICs (16.0 %) were for a recurrent tumour. Five of the tested variables were significantly associated with a patient's likelihood of receiving IPOIC after TURBT. Variables in the order of significance are as follows: (1) country (United Kingdom, patients most likely to receive IPOIC; France, least likely); (2) progression risk (physician assessed) [lower-risk conditions (no CIS, tumour < 3 cm) or intermediate risk-more likely]; (3) whether urologist completed a uro-oncology fellowship (completed-more likely); (4) recurrence risk (physician assessed) [higher-risk conditions (≥T2, ≥3 cm, CIS)-more likely]; and (5) physician's NMIBC patients volume (higher volume-more likely). Conclusions: This study revealed wide practice variation and substantial noncompliance with European Association of Urology Guidelines on the use of IPOIC after TURBT for NMIBC. [ABSTRACT FROM AUTHOR]

Young surgeons have switched immediately their daily practice into eclectic tasks (e.g., nursing patients in ICU, examining COVID patients...). The pandemic was more likely to have a negative impact on the quality of work for the most experienced urologists in training and when COVID-19 patients were hospitalized in their own urology department. Overall 76.7% had COVID-19 patients in their department, 61.5% judged themselves unable to treat their symptoms and 75.3% did not receive any updated guidelines on respiratory tract infection treatment. [Extracted from the article]

Objectives To assess the impact of lymphovascular invasion ( LVI) on upper urinary tract urothelial carcinomas ( UTUCs) in a multicentre study on cancer-specific survival ( CSS), recurrence-free survival and metastasis-free survival ( MFS)., To show the negative impact of LVI for patients with pN0/x disease and to stratify these patients into risk groups for metastatic relapse., Patients and Methods A multicentre retrospective study was performed on patients who underwent radical nephroureterectomy between 1995 and 2010., LVI status was evaluated as a prognostic factor for survival using univariate and multivariate Cox regression analysis., Results Overall, 551 patients were included and were divided into two groups: those without LVI ( LVI−), n = 388 and those with LVI ( LVI+), n = 163., LVI+ status was associated with high stage and grade UTUC and lymph node metastasis ( P < 0.001)., The 5-year CSS and MFS rates were significantly worse in the LVI+ group than in LVI− group (52.2 vs 84.5%, P < 0.001 and 43.8 vs 82.7%, P < 0.001, respectively)., In multivariate analysis, LVI+ status was an independent prognostic factor for CSS and MFS ( P = 0.04 and P < 0.001). These findings were confirmed for the pN0/x patient subgroup ( n = 504, P < 0.001)., In the pN0/x patient subgroup, we described a prognostic tool for MFS based on independent factors that permitted us to stratify patients into groups of high, intermediate or low risk of metastasis relapse., Conclusions The presence of LVI was a strong predictor of a poor outcome for UTUC., When a lymphadenectomy has not been achieved, the report of LVI status is crucial to identfiy those patients at higher risk for metastatic relapse. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the role of pelvic phased array MRI in staging prostate cancer (CaP). Materials and methods: We prospectively collected data over 12 months on CaP patients who underwent preoperative MR imaging with a pelvic phased array before radical prostatectomy. MR images were analyzed prospectively by 2 radiologists. MR imaging findings were then correlated with pathologic findings. Results: Overall, 101 patients were included with a mean PSA level of 8 (range 1.8–30). Reader 1 (AUC 0.895, 95% CI 0.791–0.999) had a higher performance than reader 2 (AUC 0.687, 95% CI, 0.555–0.819) and than DRE (AUC 0.728, 95% CI, 0.599–0.857) in discriminating T2 from T3 CaP (P = 0.01). The κ-index of inter-observer agreement was 0.56. A model that combines MRI findings, DRE, PSA, and Gleason score was the most competitive for staging (AUC 0.895, 95% CI, 0.791–0.999). For the multivariate analysis, 3 criteria were significantly associated with extracapsular extension: asymmetry of the neuro-vascular bundles (P = 0.001), asymmetric enhancement of neurovascular bundles (P = 0.02), and bulging of the capsule (P = 0.0003). Conclusion: Pelvic phased array MRI presented satisfying results in its ability to adequately stage CaP and notably in detecting the extracapsular extension of tumors. It is likely to provide reliable information but rather in the hands of an experienced radiologist. [Copyright &y& Elsevier]

Prevalence of advanced genitourinary cancer is high considering approximately 70,000 patients die annually of prostate, bladder and kidney cancer in the United States. Treatment is non-curative but along with the aim of relieving symptoms and improving quality of life, patients and doctors are driven by the goal of prolonging life. In modern urological practice, with the ever increasing number of novel therapies, clinical benefit to patients has to be measured by evaluating the trial endpoints of response and survival against adverse events. This is especially true as the population with advanced cancer is increasingly older and co-morbid. Currently, we are in a time of exponential drug development, innumerable registered trials and a vast amount of expenditure on pharmacological cancer treatment. In this era of financial uncertainty, it is even more important for clinicians to objectively assess the benefit of these expensive, moderately effective treatments that still have associated adverse sequelae. We aim to highlight the pivotal data available and put into context the survival benefit we can currently achieve with the pharmacological treatment of advanced genitourinary cancer, allowing us to critically judge whether a potentially toxic systemic treatment is worthwhile or whether it is better to defer to best supportive care. The figures presented are from the key publications that form the basis of international guideline recommendations and are the standard that newly developed treatments must emulate. [ABSTRACT FROM AUTHOR]

Objectives: According to the current upper urinary tract urothelial carcinomas (UTUC) guidelines, ureteroscopic evaluation (URS) is recommended to improve diagnostic accuracy and obtain a grade (by biopsy or cytology). However, URS may delay radical surgery [e.g., nephroureterectomy (RNU)]. The objective of this study was to evaluate the influence of URS implementation before RNU on patient survival. Methods: A French multicentre retrospective study including 512 patients with nonmetastatic UTUC was conducted between 1995 and 2011. Achievement of ureteroscopy (URS), treatment time (time between imaging diagnosis and RNU), tumour location, pT-pN stage, grade, lymphovascular invasion (LVI) and the presence of invaded surgical margins (R+) were evaluated as prognostic factors for survival using univariate and multivariate Cox regression analyses. Cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were calculated using the Kaplan-Meier method. Results: A total of 170 patients underwent ureteroscopy prior to RNU (URS+ group), and 342 did not undergo URS (URS−). The median treatment time was significantly longer in the URS+ group (79.5 vs. 44.5 days, p = 0.04). Ureteroscopic evaluation was correlated with ureteral location and lower stage and tumour grade ( p = 0.022, 0.005, 0.03, respectively). Tumour stage, LVI+ and R+ status were independently associated with CSS ( p = 0.024, 0.049 and 0.006, respectively). The 5-year CSS, RFS and MFS did not differ between the two groups ( p = 0.23, 0.89 and 0.35, respectively). These results were confirmed for muscle-invasive (MI) UTUC ( p = 0.21, 0.44 and 0.67 for CSS, RFS and MFS, respectively). Conclusions: Despite the increased time to radical surgery, diagnostic ureteroscopy can be systematically performed for the appraisal of UTUC to refine the therapeutic strategy without significantly affecting oncological outcomes, even for MI lesions. [ABSTRACT FROM AUTHOR]

Purpose: Bladder urothelial carcinoma (bladder-UC) displays distinct genotypic differences compared to upper tract UC (UTUC). We recently reported specific 8q24 SNP variants confer susceptibility to UTUC and aggressive disease features. Herein, we evaluate a bladder-UC cohort to see whether similar polymorphisms are linked similarly same way with disease risk and aggressiveness. Methods: 231 bladder-UC patients and 261 benign controls were matched for gender, age, ethnicity and smoking habits. We retrospectively retrieved information on tumour stage, grade, size, multiplicity, carcinoma in situ and tumour number. DNA was extracted from paraffin-embedded primary bladder-UC samples and blood of benign controls. Genotyping of rs9642880[T] (8q24.1) and rs798766[T] (4p16.3) was performed using commercially available Taqman assays and the ABI™ 7000 Sequence Detector. Results: Using a case-control analysis, bladder-UC risk was increased in individuals carrying the T/T genotype of rs9642880 [OR = 1.72 (95 % CI 1.1-2.8); p = 0.028] and rs798766 [OR = 1.84 (95 % CI 0.9-2.3); p = 0.01]. When analysing parameters of bladder-UC aggressiveness, the T/T genotypes for rs9642880 and rs798766 were not found to be associated with either grade [OR = 0.89 (95 % CI 0.52-1.32; p = 0.68) and OR = 0.95 (95 % CI 0.58-1.48; p = 0.61), respectively] or pathological stage [OR = 0.79 (95 % CI 0.42-1.48; p = 0.46) and OR = 0.90 (95 % CI 0.49-1.61; p = 0.72), respectively]. SNP variability of rs9642880[T] and rs798766[T] is associated with an increased risk of bladder-UC but we did not find an association with disease aggressiveness as we did previously for UTUC. Conclusions: This is further evidence of the distinct genetic differences that exist between bladder-UC and UTUC, and it is not possible to extrapolate results of genetic studies between these two urothelial disease entities. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Urinary incontinence is one of the major drawbacks of radical prostatectomy, regardless of the procedure used (i.e. open, laparoscopic or robotic-assisted). Several technical modifications have been described to improve postoperative continence, highlighting the role of puboprostatic ligaments and posterior reconstruction of the rhabdomyosphincter. The results obtained are inconsistent when applied to robotic surgery. The present multicentre randomized study shows that anterior suspension combined with posterior reconstruction is a safe and easy-to-perform technique for improving early continence after robotic-assisted laparoscopic prostatectomy. OBJECTIVE To assess the impact on urinary continence of anterior retropubic suspension with posterior reconstruction during robot-assisted laparoscopic prostatectomy (RALP)., PATIENTS AND METHODS In total, 72 patients who were due to undergo prostatectomy between July 2009 and July 2010 were prospectively randomized into two groups: group A underwent a standard RALP procedure and group B had anterior suspension and posterior reconstruction during RALP., The primary outcome measure was urinary continence, assessed using the University of California Los Angeles Prostate Cancer Index questionnaire at 15 days, and at 1, 3 and 6 months, after surgery. Other data recorded were operation duration, blood loss, length of hospital stay, duration of bladder catheterization, complications and positive margin rate., RESULTS The continence rates at 15 days, and at 1, 3 and 6 months, after surgery were 3.6%, 7.1%, 15.4% and 57.9%, respectively, in group A, and 5.9%, 26.5%, 45.2% and 65.4%, respectively, in group B. The continence rates differed statistically between groups at 1 and 3 months ( P = 0.047 and P = 0.016, respectively)., There was no significant difference between groups regarding complications ( P = 0.8) or positive margin rate ( P = 0.46)., CONCLUSION Anterior suspension associated with posterior reconstruction during RALP improved the early return of continence, without increasing complications. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To investigate whether overexpression of p53, MIB-1, and Aurora-A on protein level played a role in the relapse of urothelial carcinomas of the upper urinary tract (UC-UUT). Materials and methods: The following data from the files of 42 patients treated for UC-UUT were collated: age, prior history of cancer, tumor stage and grade, and disease progression. Immunohistochemistry (IHC) for p53, MIB-1, and Aurora-A was performed on tissue microarray sections from tumor tissue. Results: Patients aged 46 to 100 years (mean 70.6 years). Overall, 23 (54%) patients died from progression of UT-UCC. The surgical stage was significantly associated with MIB-1 and Aurora-A overexpression (P = 0.004 for each). Univariate analysis showed that relapse was significantly associated with ureteral localization (P = 0.02), the presence of vascular invasion (VI) (P = 0.003), high grade (P = 0.04), high stage UT-UCCs (P = 0.02), and p53 (P = 0.01), Aurora-A (P = 0.01), and MIB-1 overexpression (P = 0.02). In multivariate analysis, relapse was associated with high grade (P = 0.04), high stage (P = 0.04), VI (P < 0.0001, respectively), and p53 (P = 0.04) and Aurora-A (P = 0.02) overexpression but not with MIB-1 overexpression (P = 0.06). In addition, expressions of p53, MIB-1, and Aurora-A were significantly associated with presence of VI (P = 0.008, P = 0.001, and P = 0.003, respectively). Conclusion: Aurora-A and p53 are important factors in UC-UUT development and might be useful as independent factors for predicting clinical outcome and presence of VI. Aurora-A seems to influence the development of VI and tumor aggressiveness via a mechanism not clearly elucidated yet. [Copyright &y& Elsevier]

Introduction and hypothesis: As the subsequent risks of complications and explantation increase with the size of the cuff, we aimed to assess functional outcomes after the implantation of an artificial urinary sphincter (AUS) with a large cuff (≥8 cm) in women with severe urinary incontinence. Methods: Fifty women underwent an AUS placement with a large cuff between 1984 and 2007. Forty-three (86%) had previously undergone anti-incontinence procedures. The AUS was implanted with an open surgical technique using a transverse abdominal approach. The cuff was placed around the bladder neck between the periurethral fascia and the vagina. Perioperative complications were reviewed. To assess the resolution of urinary incontinence, all patients were seen at 1, 3, 6 and 12 months and yearly thereafter. Results: The mean age was 59 ± 12.4 years (26-81). The mean BMI was 27.3 ± 5.1 (19-37). The mean pre-operative closure pressure was 19.1 ± 9.4 cmHO (3-46). The mean hospital stay was 14.1 ± 5 days (5-28). The mean follow-up was 8 ± 5.6 years. Incontinence was completely resolved in 34 women (68%). The protective factors to avoid explantation were a number of gestations less than two ( p = 0.04), a closure pressure higher than 19 cmHO ( p = 0.04) and a cuff size equivalent to 8 cm ( p = 0.005). Conclusions: Specific anatomical conditions can sometimes lead to AUS implantation with a large cuff with encouraging outcomes. Thus, surgeons should not be reluctant to place a large cuff when the situation requires it. [ABSTRACT FROM AUTHOR]

Objective: To assess the outcome of cutaneous noncontinent urinary diversion (CNCUD) for neurogenic bladder management in multiple sclerosis (MS) patients. Methods: We retrospectively reviewed the charts of our MS patients who underwent surgery for CNCUD between 1994 and 2009. To assess the impact of urinary problems on health-related quality of life (HRQOL), a Qualiveen questionnaire was completed by the patients (scale 0 = no impact of urinary problems and 4 = high adverse impact). Results: Overall, 53 patients with a median age of 51 years were included in the study. The mean Expanded Disability Status Scale score before surgery was 7.48 ±1.02 (range 6.5-9). The mean duration of follow-up was 73 months (range 6-168). The complication rate was 55%. Minor postoperative complications (Clavien grades I-II) occurred in 23 cases, and major complications (Clavien grades III-IV) occurred in 6 cases. The mean creatinine levels before surgery and at the last follow-up were 0.63 ± 0.2 mg/dL and 0.73 ± 0.53 mg/dL, respectively. The mean overall HRQOL scores before surgery and at last follow-up, and which assess the impact of the urinary problems on the patient, were 2.1 ± 1.18 and 1.16 ± 0.63 (P = .02), respectively. Conclusion: Cystectomy and CNCUD are indicated in MS-impaired patients who are refractory to medical treatment and they can result in disappearance of neurological bladder symptoms. CNCUD appears to be the procedure of choice to improve the quality of life of selected patients, despite the fact that it is associated with high perioperative morbidity. [ABSTRACT FROM AUTHOR]

Abstract: Background: Women are increasingly entering the medical studies. We aim to investigate surgical residents'' career decision making among surgical residents and to assess the presence of women. Methods: An “electronic questionnaire” of self-assessment was distributed to the 2,500 current French surgical residents. Items analyzed included population characteristics, demographics, educational experiences, and choice of career. Results: There was a response rate of 31.2% (n = 779). The male/female ratio was 1.1 with 370 women (47.5%). The mean age was 28 ± 2 years. All surgical specialties were represented. Sex was significantly associated with the choice of surgical specialty (P < .05). Female residents had a shorter working time per week than male residents (P < .001). Sex was significantly linked with future career plans as female residents expected to work in a public hospital (P = .005) and as male residents expected to work in private practice (P = .001). Conclusions: Female surgical residents are more populous than ever among surgical residents. Sex appears to be linked with where and how the residents expect to work in the future. [Copyright &y& Elsevier]

Background: A robot-assisted laparoscopic approach for radical prostatectomy (RALRP) is being adopted increasingly worldwide for the treatment of localized prostate cancer (CaP). Complications assessment is essential to the objective evaluation of any new procedure. This study aimed to assess the perioperative complications encountered during the implementation of a robot-assisted urologic surgery program. Methods: A prospective data collection for all men with a diagnosis of CaP who underwent RALRP between 2005 and 2009 in our department was achieved. Together with perioperative data, all the perioperative complications encountered were specifically recorded, including robot dysfunctions. The RALRP was performed with the three-arm Da Vinci system using a transperitoneal approach with six ports. To assess the perioperative complications, the validated Clavien-Dindo classification of surgical procedures was used. Two surgeons were involved in these procedures. A modified Clavien-Dindo classification also was used to account for intraoperative complications. Results: According to the Clavien-Dindo classification, 16 complications (6.7% complication rate) were recorded during the first 240 procedures. Besides postoperative complications, five procedures (2.1%) were directly affected by robot malfunctions without notable consequences for the patients. Considering these five additional complications, an 8.8% complication rate was recorded using a modified Clavien-Dindo classification. The main limitation of the study was its design restricted to RALRP procedures alone. The second limitation was that the authors' modified classification needs to be validated with a larger series and for different surgical procedures. Conclusions: The findings show that RALRP is a safe alternative to classical surgery and that the robotic approach is reliable. The authors believe that the reliability of technological devices should be systematically discussed when outcome analysis of a new procedure is performed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Tension-free vaginal tape (TVT) has been largely used for the management of stress urinary incontinence. In certain cases, however, this procedure results in bothersome complications that lead to a complete resection. Objective: We assessed the technical feasibility and functional outcome after complete laparoscopic resection of TVT. Design, setting, and participants: Thirty-eight women with TVT-related complications refractory to first-line management underwent a complete laparoscopic tape resection between 2001 and 2009. Surgical procedure: Complete laparoscopic resection was achieved with either an intra- or extraperitoneal laparoscopic approach. Laparoscopy was performed with four ports: a 10-mm umbilical telescope port, two 5-mm ports placed medially to the anterior superior iliac spines, and a 10-mm port placed at the midpoint between the pubis and umbilicus. The two half-tapes were dissected towards the urethra and removed. Measurements: All data referring to patient demographics, surgery, tape-related complication, and perioperative outcomes were recorded. Results and limitations: The mean age of the patients was 66.2 yr (range: 45–79 yr). TVT-related complications included bladder erosion, vaginal extrusion, and bladder outlet obstruction or groin pain. The resection took place at a mean time of 25 mo (range: 6–80 mo) after TVT placement. Resection was complete in all patients, within a mean operative time of 110min (range: 50–240min). All women reported a total decrease of symptom-related complications within a mean follow-up period of 37.9 mo (range: 2–80 mo). However, recurrent incontinence occurred in 65.7% (n =25) of the patients. The main limitation of the study was the lack of a validated questionnaire to assess the evolution of functional disorders. Conclusions: Complete laparoscopic resection of TVT is safe and technically feasible. In the limited number of women who have persisting disabling symptoms after conservative management, urologists must be aware that a complete resection can help resolve the symptoms. [Copyright &y& Elsevier]

To assess oncological outcome after first-line management of upper urinary tract urothelial cell carcinomas (UUT-UCCs) by exclusive flexible ureteroscopy. A retrospective review was performed for 35 patients treated between 2003 and 2007. All patients underwent retrograde flexible ureteroscopy for diagnosis, treatment (i.e., holmium:YAG vaporisation), and follow-up. The following data were reviewed: sex, age, ASA score, presence of a solitary kidney, unifocal or multifocal tumour, history of bladder cancer, tumour localisation, tumour size, stage and grade, outcome, recurrence, and progression. The mean age was 67 ± 13.1 years (range: 38–88). The tumour involved the renal pelvis and the caliceal system in 19 cases (54%), the ureter in 8 cases (23%), and both in 8 cases (23%). Twelve patients (34%) had a history of bladder carcinoma. Tumour stage was superficial in 63% (57% were pTa and 6% were pT1) and not available in 37%. Tumour grade was low, high, and unavailable in 49, 14, and 37%, respectively. The median follow-up was 30 months (range: 12–66), and 21 patients had a recurrence (60%). The median survival rate without recurrence was 10 months (95% CI [5–22]). Four patients underwent nephroureterectomy during follow-up. No patient died of disease progression. The main limitation was the limited length of follow-up. Flexible endoscopic management can be advocated in selected cases of non-muscle invasive UUT-UCCs as an alternative to nephroureterectomy. Because of a high recurrence rate, long-term and stringent surveillance is needed, including iterative ureteroscopies at least every 3 months for 2 years. [ABSTRACT FROM AUTHOR]

Abstract: Background: Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI). Objective: To assess the early functional outcome after laparoscopic placement of an AUS in women. Design, setting, and participants: Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures. Intervention: The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina. Measurements: Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter. Results and limitations: The mean age of subjects was 56.7±12 yr (33–78). The mean body mass index was 24±2.3 (20–25). The mean preoperative closure pressure was 22±10.9cmH2O (4–35). The mean operative time was 181±39min [110–240]. Intraoperative complications occurred in three women (25%), with bladder (n =2) and vaginal (n =2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7±2.3 d (3–11). The bladder catheter was removed after a mean time of 10±8 d (2–30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4–14 wk after implantation. Mean follow-up was 12.1±8 mo (5.2–27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up. Conclusions: AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy. [Copyright &y& Elsevier]

OBJECTIVE To establish the predictive accuracy of the Kattan preoperative nomogram by comparing predictions at 5 years with actual progression in patients who had a radical prostatectomy (RP). MATERIALS AND METHODS We reviewed the data for 928 patients treated by RP as a first-line treatment for localized prostate cancer, between 1994 and 2005. Recurrence was defined as one prostate-specific antigen (PSA) level of >0.4 ng/mL. The 5-year progression-free probability (PFP) rate was evaluated on censured data using the Kaplan-Meier method. Relationships between all predictor variables included in the Kattan nomogram (PSA level, biopsy Gleason scores and clinical stage) and survival were evaluated by Cox proportional-hazards regression analysis. The discriminating ability of the nomogram was assessed by the concordance index ( c-index). Bootstrapping was used to assess confidence intervals (CIs), and then the calibration was assessed. RESULTS The median follow-up was 60 months. Overall, 177 (19%) patients had a recurrence; the 5-year PFP rate (95% CI) was 80.9 (78–83)%. Of the three variables included in the nomogram, all were associated with recurrence in a multivariate analysis ( P < 0.001). The c-index (95% CI) was only 0.664 (0.584–0.744). In general, the nomogram was not well calibrated. CONCLUSIONS There was a discrepancy between the predicted PFP as estimated by the Kattan nomogram and actual relapse in this group of patients. Clinicians should be aware that the nomogram is less accurate when used outside the population used to formulate the nomogram. Although more accurate tools are needed, the Kattan nomogram is still the best choice for urologists so far. [ABSTRACT FROM AUTHOR]

To assess the oncological safety of laparoscopic procedures for the management of urothelial carcinomas of the urinary tract. Data on laparoscopic management of urothelial carcinomas in the literature were analysed using MEDLINE and by matching the following keywords: urological malignancies, upper tract tumours, bladder carcinomas, laparoscopic approach, recurrence, follow-up and metastasis site. Minimally invasive techniques are being used increasingly in the management of these tumours and successfully achieving the benefits of lower blood loss and more rapid patient recovery. To date, no evidence level 1 information is available and published series of these technically challenging cases are small and follow-up limited. Short to medium term follow-up appears encouraging in terms of recurrence and survival rates, but long-term data are immature compared to the established open techniques these procedures seek to duplicate. Specific concerns in terms of the oncologic safety of laparoscopy, especially with regard to the pneumoperitoneum, tumour manipulation and specimen extraction are addressed. Port-site metastases and tumour seeding are rare events and appear to be mainly related to the grade and stage of the tumour. Specific precautions are required to minimise these risks. Oncological results of the laparoscopic approach are difficult to compare with those of open surgery. However, recent series have not reported unusual tumour dissemination or a higher rate of recurrence with this approach. Laparoscopic techniques are not yet standard of care in invasive urothelial carcinomas. Long-term assessment is ongoing and awaited. [ABSTRACT FROM AUTHOR]

Abstract: Context: The data describing the urologic extracolonic cancers associated with hereditary nonpolyposis colorectal cancer (HNPCC) are variable. Objective: Provide an update about the current urologic tumor spectrum in HNPCC. Evidence acquisition: Data on HNPCC extracolonic tumor spectrum published in the literature were analysed using MEDLINE with emphasis on urological malignancies, upper tract tumors, clinical criteria, genetic diagnosis and counselling. Evidence synthesis: HNPCC is a form of colorectal cancer with a dominant autosomal mode of inheritance. HNPCC is caused by germ-line mutations affecting one or several mismatch repair genes. Cancers other than colorectal cancer are sometimes associated with HNPCC. These include specific urological malignancies, most notably tumors of the upper urinary tract, which have been reported to occur at a rate ×22 higher than the general population. Upper urinary tract tumors rank third (5%) after colon (63%) and endometrial (9%) cancer within the group of HNPCC related tumors. Prostate cancer and testicular germ cell tumors are rarely associated. Due to lack of appreciation of such hereditary associations, some inherited cancers are still misclassified as sporadic and their incidence is underestimated. The biological tests requested in suspected cases of HNPCC are: microsatellite instability (MSI) analysis, immunohistochemistry and DNA sequencing. When gene mutations are detected, the patient and their family will benefit from a multidisciplinary management approach. The presence of other HNPCC-associated cancers is sought and close monitoring of patients is undertaken. Genetic counselling is provided to the patient’s family. Conclusions: The recognized urologic tumor spectrum in HNPCC includes upper tract tumors. However, in order not to overlook a hereditary cancer, urologists should be aware of the possible urological malignancies associated with HNPCC (i.e., prostate and testicular carcinomas) and evaluate appropriately anyone they feel are at high risk of underlying HNPCC based on set clinical criteria. [Copyright &y& Elsevier]

To assess the long term oncologic results of high-intensity focused ultrasound therapy (HIFU) as a primary and single treatment for clinically localized prostate cancer. A total of 119 patients with clinically localized prostate cancer underwent HIFU (Ablatherm®, EDAP, France) as first-line treatment and were retrospectively reviewed. They were stratified according to risk groups proposed by D’Amico. No patient had undergone previous hormonal therapy. PSA level was monitored at 3, 6, 12, 18, 24 months and then yearly. According to the latest ASTRO criteria, failure was defined by a PSA rise of 2 ng/ml or more above the PSA nadir. The biochemical-free survival rate (BFSR) was calculated. Mean patient age was 68 ± 7.8 years (46–83). Mean follow-up was 3.9 years (1–6.8). Overall 52 patients (43.7%) experienced a biochemical recurrence which included 26, 23 and 3 patients in the low, intermediate and high-risk groups, respectively. In univariate and multivariate analyses, there was a statistical association between preoperative PSA value > 10, a nadir PSA value > 1 and the risk of biochemical recurrence ( P < 0.05). The 5-year BFSR rate was 30% with no statistical difference between low- and intermediate-risk patients. None of the 119 patients died of prostate cancer. High-intensity focused ultrasound therapy provides efficient oncologic control only in patients with low-risk prostate cancer. However, our data could be used to improve the selection of patients who are potential candidates for HIFU therapy. [ABSTRACT FROM AUTHOR]

OBJECTIVE To compare the potential of two diagnostic methods for detecting recurrence of urothelial cell carcinoma (UCC) of the bladder, by (i) detecting alterations in microsatellite DNA markers and loss of heterozygosity (LOH), and (ii) detecting aberrant gene hypermethylation, as UCC has a high recurrence rate in the urinary tract and the disease can invade muscle if new tumours are overlooked. PATIENTS AND METHODS Over 1 year, urine samples were retrieved from 40 patients already diagnosed with bladder UCC (30 pTa, two pTis, eight pT1). Samples were collected 6 months after bladder tumour resection, during the follow-up schedule. We used samples to analyse nine microsatellite markers and the methylation status of 11 gene promoters. Receiver operating characteristic curves were generated and Bayesian statistics used to create an interaction network between recurrence and the biomarkers. RESULTS During the study, 15 of the 40 patients (38%) had a tumour recurrence and 14 were identified by cystoscopy (reference method). Overall, microsatellite markers (area under curve, AUC 0.819, 95% confidence interval, CI, 0.677–0.961) had better performance characteristics than promoter hypermethylation (AUC 0.448, 0.259–0.637) for detecting recurrence. A marker panel of IFNA, MBP, ACTBP2, D9S162 and of RASSF1A, and WIF1 generated a higher diagnostic accuracy of 86% (AUC 0.92, 0.772–0.981). CONCLUSION Microsatellite markers have better performance characteristics than promoter hypermethylation for detecting UCC recurrence. These data support the further development of a combination of only six markers from both methods in urinary DNA. Once validated, it could be used routinely during the follow-up for the early detection and surveillance of UCC from the lower and upper urinary tract. [ABSTRACT FROM AUTHOR]

OBJECTIVE To analyse the incidence and the risk of developing de novo stress urinary incontinence (SUI) after laparoscopic sacral colpopexy (LSCP). PATIENTS AND METHODS In all, 53 women wit no concomitant or occult SUI before surgery had a LSCP with no anti-incontinence procedure. All their medical charts were reviewed retrospectively and analysed statistically to assess the association between clinical data before LSCP (age, body mass index, maximum urethral closure pressure, medical history of UI and prolapse surgery, bladder neck hypermobility) and de novo SUI after LSCP. RESULTS With a mean (sd) follow up of 20.4 (9.1) months, seven patients (13%) developed de novo SUI, within a median (range) of 2.1 (1–3) months after surgery. There was no statistical association between factors before LSCP and de novo SUI afterward on a univariate analysis ( P > 0.05). The 5-year SUI-free survival rate after LSCP was 86%. CONCLUSION Despite the risk of de novo SUI remaining low after LSCP patients should always be informed before surgery, as it cannot be predicted. Moreover, it can directly affect the functional outcome and lead to a second procedure in a few cases. [ABSTRACT FROM AUTHOR]

The mini reviews this month cover two somewhat unusual topics, but I feel certain that they will be of interest to the readership. Metachronous TCC in the upper urinary tract after radical cystectomy has been an important topic in relation to the follow-up, and this paper throws considerable light on the subject. The second paper is an excellent review of the literature on emphysematous cystitis. Urothelial carcinoma is characterized by multiple, multifocal recurrences throughout the genitourinary tract; ≈ 3% of patients treated by radical cystectomy (RC) for invasive transitional cell carcinoma (TCC) of the bladder will subsequently develop a subsequent TCC in the upper urinary tract (UUT) urothelium. Metachronous upper UUT tumours (mUUT-TCC) typically occur as a late oncological event (>3 years after RC). The vast majority of mUUT-TCCs are detected only after the progression to tumour-related symptoms, e.g. haematuria, flank pain or pyelonephritis, despite strict adherence to surveillance protocols. Failure of imaging and cytology to detect most asymptomatic tumours has led to questions about the need for routine UUT surveillance. Some authors have advocated a more tailored approach to surveillance after RC, targeting high-risk patients and with limiting imaging in those patients at lowest risk of developing a subsequent UUT-TCC. mUUT-TCCs are most common in patients with TCC in the ureter or urethra, and with organ-confined bladder cancer. Although the prognosis is generally poor, long-term survival can be achieved in a subset of patients after radical nephroureterectomy (NU). Minimally invasive techniques, e.g. ureteroscopic and percutaneous resection, have been proposed as renal-sparing alternatives to radical surgery for patients with low-stage and -grade de novo UUT-TCC. However, oncological control of renal-sparing therapies in those with high-risk mUUT-TCC remains largely unconfirmed. Until oncological outcomes equivalent to the standard, radical NU, are reported in patients after RC, conservative treatment strategies should be avoided. [ABSTRACT FROM AUTHOR]

Objectives: To determine the surgical and oncologic outcomes in patients who underwent either open nephroureterectomy (ONU) or laparoscopic nephroureterectomy (LNU) for upper urinary tract transitional cell carcinoma. Methods: We performed a retrospective review of data for patients who underwent ONU or LNU for upper urinary tract transitional cell carcinoma from 1994 to 2004 at one institution. The recorded data included sex, age, mode of diagnosis, smoking, history of bladder cancer, type of surgery, complications, tumor site, tumor size, tumor stage, tumor grade, length of hospital stay, recurrence, and progression. We also determined the recurrence and survival rates. Results: We reviewed the data for 46 patients. The median age was 70 years. Seven patients had a history of bladder cancer. Overall, 26 patients underwent ONU and 20 LNU. No differences in the complication rate (15% versus 15%) were observed. The median hospital stay was 4 days (range 3 to 6) after LNU and 9 (range 7 to 12) after ONU (P <0.001). The tumor stage and grade were independent prognostic factors for survival on multivariate analysis (P <0.05). The 5-year disease-specific survival rate was 89.4% for low-grade tumors and 63.1% for high-grade tumors (P = 0.04). ONU was associated with high-grade (P = 0.02) or invasive (P = 0.001) tumors. The 5-year tumor-free survival rate after ONU and LNU was 51.2% and 71.6%, respectively (P = 0.59). Conclusions: LNU does not affect the mid-term oncologic control and enables a shorter hospital stay. It can be recommended as an alternative to ONU in the management of low-risk upper urinary tract transitional cell carcinoma (Stage T1-T2 and/or low-grade disease). However, long-term follow-up is necessary to recommend it for highly invasive tumors (Stage T3-T4 or N+). [Copyright &y& Elsevier]

Associate Editor Ash Tewari Editorial Board Ralph Clayman, USA Inderbir Gill, USA Roger Kirby, UK Mani Menon, USA OBJECTIVE To determine the surgical feasibility and early oncological outcomes of laparoscopic distal ureterectomy in patients with low-grade upper urinary tract transitional cell carcinoma (UUT-TCC). PATIENTS AND METHODS We retrospectively reviewed patients treated laparoscopically with conservative management for a UUT-TCC between 2001 and 2005. We collected data on gender, age, mode of diagnosis, smoking, history of bladder cancer, complications, tumour site, size, stage, grade, hospital stay, recurrence and progression. RESULTS Data were analysed for six patients with a mean (range) age of 68.5 (54–76) years. Four patients had a diagnostic ureteroscopy with biopsy. The operative duration was 173.3 (120–240) min, the estimated blood loss was 75 (50–200) mL and the length of ureteric resection was 5.23 cm. Two patients required a psoas hitch. JJ stents were maintained for 25.8 (15–30) days. The hospital stay was 6 (5–8) days. There were minor complications in three patients after surgery. The follow-up was 32 (17–46) months. The tumour size was 1.7 (0.8–2.6) cm. There were low-grade tumours in four patients and pTa in five. All patients are alive and free of disease; there were no anastomotic strictures. Two patients developed a recurrence, one in the ipsilateral renal pelvis and one in the bladder. CONCLUSION Laparoscopic distal ureterectomy with direct re-implantation is technically feasible for low-risk UUT-TCC (i.e. low-grade, noninvasive), in the properly selected patient. Early oncological outcomes are promising but strict surveillance protocols must be followed. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To assess oncologic outcomes in patients undergoing percutaneous management for upper urinary tract transitional cell carcinoma (UUT-TCC) of the renal cavities. Methods: We performed a retrospective review of data for patients who underwent percutaneous conservative surgery for a UUT-TCC between 1989 and 2005: sex; age at diagnosis; mode of diagnosis; smoking; history of bladder cancer; type of surgery; complications; tumour site, size, stage and grade, and recurrence and progression. We evaluated recurrence and survival rates. Results: Data were analyzed for 24 patients. Median age was 70 yr. The tumour was located in the renal pelvis in 11 patients and in the caliceal system in 13 patients. Mean tumour size was 1.8cm (range: 0.8–2.9). Four patients had a history of bladder carcinoma. Three patients experienced perioperative blood loss requiring transfusion, and one experienced colon wound. Median follow-up was 62 mo. Eight (33.3%) patients experienced local recurrence (three in the treated urinary tract, one in the contralateral tract, four in the bladder). Five patients underwent nephroureterectomy (NUT) during follow-up. Five (20.8%) patients have died, four from disease progression and one from cardiovascular causes. The 5-year disease-specific and tumour-free survival rates were 79.5% and 68%, respectively. Conclusions: Percutaneous management can be recommended as an alternative to NUT or ureteroscopy for low-grade or superficial UUT-TCCs localised in the renal cavities. These patients require long-term postsurgical surveillance. For patients with high-grade or invasive tumours, open NUT remains the gold standard. [Copyright &y& Elsevier]

Abstract: Objectives: To compare the outcomes in patients who had undergone either open nephroureterectomy or conservative endoscopic surgery (ureteroscopic or percutaneous management) for upper urinary tract transitional cell carcinoma. Methods: We performed a retrospective review of the data for patients treated surgically for upper urinary tract transitional cell carcinoma from 1990 to 2004. The data included patient sex, age at diagnosis, mode of diagnosis, smoking history, history of bladder cancer, type of surgery, complications, and tumor site, size, stage, grade, recurrence, and progression. We also evaluated the recurrence and survival rates. Results: Data were analyzed for 97 patients. The median patient age was 68 years. Sixteen patients had a history of bladder tumor. The surgical procedure was open nephroureterectomy in 54 patients, ureteroscopy in 27, and percutaneous endoscopic ablation in 16. The tumor stage, grade, and site were independent prognostic factors for survival in a multivariate analysis (P <0.05). The 5-year disease-specific survival rate was 81.9% for low-grade tumors and 47.3% for high-grade tumors (P = 0.0001). A correlation (P = 0.002) was found between low-grade tumors and superficial tumors. In patients with low-grade tumors (n = 46), the 5-year disease-specific survival rate after nephroureterectomy, ureteroscopy, and percutaneous endoscopy was 84%, 80.7%, and 80%, respectively (P = 0.89); the corresponding 5-year tumor-free survival rates were 75.3%, 71.5%, and 72% (P = 0.78). Conclusions: Conservative surgery can be recommended as an alternative to nephroureterectomy for low-grade or superficial upper urinary tract transitional cell carcinoma. For patients with high-grade or invasive tumors to be candidates for conservative surgery will require the development of additional prognostic factors (eg, molecular markers). These patients require long-term postoperative surveillance. [Copyright &y& Elsevier]

Abstract: Objectives: To establish the cancer control afforded by radical prostatectomy in patients aged 50 years or younger with sporadic, familial, or hereditary prostate cancer. Methods: We collected data on all patients 50 years old or younger among 5880 patients treated for prostate cancer between 1994 and 2004. We recorded age, ethnic origin, clinical presentation, family history of prostate cancer, preoperative prostate-specific antigen (PSA) level, treatment, Gleason score, 2002 TNM stage, surgical margin status, and disease progression. Radical prostatectomy was offered as first-line treatment to all patients with localized prostate cancer (T1-T2N0M0) and negative lymph nodes. PSA-free survival was calculated. Results: We analyzed the data from 110 patients (1.9%), of whom 37 had familial cancer (33.6%) and 15 hereditary cancer (13.6%). A total of 85 patients (77.3%) had undergone radical prostatectomy, 39 (45.9%) by open retropubic surgery and 46 (54.1%) laparoscopically. The surgical margins were positive in 11 patients (12.9%). The mean follow-up after prostatectomy was 39.1 ± 36.8 months (range 4 to 125). Nine patients (10.6%) experienced biochemical recurrence (PSA level greater than 0.2 ng/mL). Longer PSA-free survival after surgery was significantly associated with high-risk and intermediate-risk patients (P = 0.01 and P = 0.02, respectively) but not with the surgical procedure (P = 0.6) or family history of cancer (P = 0.46). Conclusions: Radical prostatectomy is an effective treatment of localized cancer in patients younger than 50 years old. Nearly one half of our cases of prostate cancer in younger men were forms of familial cancer. Detecting familial forms is a key objective in early screening and in the timely identification of candidates for prostatectomy. [Copyright &y& Elsevier]

Abstract: Objectives:: Invasive upper urinary tract transitional cell carcinoma (UUT-TCC) has a poor prognosis (survival <50% at 5 years), and tumor stage and grade often fail to predict outcome. Our purpose was to establish whether the expression of Ki67, p53, p27, E-cadherin, survivin or MSH2 can provide prognostic information in UUT-TCC. Methods:: The following data from the files of 62 patients treated for UUT-TCC over 12 years were collated: age at diagnosis, prior history of cancer, tobacco consumption, tumor stage (including surgical margins) and grade, and disease progression. Immunohistochemistry (IHC) for Ki67, p53, p27, E-cadherin, survivin and MSH2 was performed on tissue microarray sections from tumor tissue. Results:: Overall, 31 patients died with metastasis from UUT-TCC. Mean survival was 20±16 months (range 2–83). In a univariate analysis, advanced age (>68 years), high stage, and loss of E-cadherin and high Ki67 expression were associated with a poor prognosis and disease recurrence. In a multivariate analysis, the independent factors of prognosis and recurrence were E-cadherin (p =0.001; p =0.004), age (p =0.022; p =0.008), and high stage (p =0.023; p =0.008). Conclusions:: E-cadherin is a useful independent prognostic factor in UUT-TCC, for use in addition to age and tumor stage. It is of particular interest to predict recurrence in patients with low grade non-invasive tumors. Ki67 expression is informative but less significant. Survivin, p53, p27 and MSH2 have no prognostic value. [Copyright &y& Elsevier]

Reports on the microsatellite instability and transitional cell carcinoma of the upper urinary tract. Prognostic factors, recurrence and survival in transitional cell carcinoma of the upper urinary tract; Impact of tumor location on prognosis of transitional cell carcinoma of the upper urinary tract; Risks and screening options for urinary tract cancer and hereditary nonpolyposis colorectal cancer.

Abstract: Objectives: To determine the value of mid-infrared spectroscopy (MIRS) of ureteral stent encrustations in predicting urinary stone composition. Methods: A retrospective study analyzed the composition of stent encrustations and urinary stones by MIRS in patients who had had a stent for ureteral obstruction between 2001 and 2003. The overall correlation was evaluated. The correlation coefficient kappa for agreement between the proportions of each component was calculated. Results: A total of 72 stents and 72 stones from 72 patients were analyzed. The mean stent indwelling time was 55.5 days (range 14 to 102). The stents had been placed for fever (52 cases, 72%), pain refractory to analgesics (15 cases, 21%), and impairment of kidney function (5 cases, 7%). The overall correlation between stone composition and stent encrustation was 71.4%, excluding biofilm analysis. The kappa value was 0.78 for the main component (n = 72; P &#60;0.0005), 0.61 for the secondary component (n = 72; P &#60;0.0005), and 0.91 for the agreement between the composition of encrustations at each end of a stent (n = 30; P &#60;0.0005). Conclusions: MIRS analysis of stent encrustations is a reliable method of predicting stone composition when the stone cannot be retrieved. Systematic MIRS analysis of stent encrustations is not recommended but can be very useful in clinical situations in which no stone is available. [Copyright &y& Elsevier]