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The article presents abstracts on urology topics which include radical prostatectomy to treat localised prostate cancer, the effects of a standardised exercise and lifestyle modification programme on the adverse effects of androgen suppression therapy (AST) and the effect of radical prostatectomy (RP) delay on postoperative functional outcomes of North Americans.

Objectives: To apply a new evidence-gathering methodology, called reverse systematic review (RSR), to analyse the influence of different continence classification criteria on urinary continence rates among open retropubic radical prostatectomy (RRP), laparoscopic RP (LRP) and robot-assisted RP (RARP)., Materials and Methods: A search was carried out in eight databases between 2000 and 2020 through systematic reviews (SRs) studies referring to RRP, LRP or RARP (80 SRs). All references used in these SRs were captured referring to 910 papers in an overall database called the 'EVIDENCE Database'. A total of 422 studies related to post-RP urinary continence were selected for the final analysis, totalling 782 reports referring to 193 618 patients., Results: Overall, 206 (26.4%) reports for RRP, 243 (31.0%) reports for LRP, and 333 (42.6%) reports for RARP were found. Mean overall continence rates, respectively for RRP, LRP and RARP, were: 42%, 34% and 42% at 1 month; 62%, 64% and 65% at 3 months; 73, 77 and 79% at 6 months; and 81%, 85% and 86% at 12 months. The most used criterion was 'No pad' (53.3%), followed by 'Safety pad' (19.3%), 'Not described' (10.6%), and 'No leak' (9.9%). 'No pad' showed the lowest discrepancy in continence rates in each period compared to the overall average for each technique, demonstrating less ability to influence the final results favouring any of the techniques., Conclusion: The RSR demonstrated that the 'No pad' criterion was the most used in the literature and showed the lowest bias capable of influencing the results and favouring any of the techniques and is the fairest option for future comparisons., (© 2023 BJU International.)

Objective: The aim of the paper is to provide an overview of intraoperative sampling methods for frozen section (FS) analysis and of surgical techniques for a secondary neurovascular bundle (NVB) resection, as the method of surgical margin (SM) sampling and the management of a positive SM (PSM) at the nerve‐sparing (NS) area are under evaluated issues. FS analysis during radical prostatectomy (RP) can help to tailor the plane of dissection based on cancer extension and thus extend the indications for NS surgery. Evidence Acquisition: We performed a PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science, Cochrane Library, and Elton B. Stephens Co. (EBSCO)host search to include articles published in the last decade, evaluating FS analysis in the NS area and surgical attempts to convert a PSM to a negative status. Evidence Synthesis: Overall, 19 papers met our inclusion criteria. The ways to collect samples for FS analysis included: systematic (analysing the whole posterolateral aspect of the prostate specimen, i.e., neurovascular structure‐adjacent frozen‐section examination [NeuroSAFE]); magnetic resonance imaging (MRI)‐guided (biopsies from MRI‐suspicious areas, retrieved by the surgeon in a cognitive way); and random biopsies from the soft periprostatic tissues. Techniques to address a PSM in the NS area included: full resection of the spared NVB, from its caudal to cranial aspect, often including the rectolateral part of the Denonvilliers' fascia; partial resection of the NVB, in cases where sampling attempts to localise a PSM; incremental approach, meaning a partial or full resection that extends until no prostate tissue is found in the soft periprostatic environment. Conclusions: There is no homogeneity in prostate sampling for FS analysis, although most recent evidence is moving toward a systematic sampling of the entire NS area. The management of a PSM is variable and can be affected by the sampling strategy (difficult localisation of the persisting tumour at the NVB). The difficult identification of the exact soft tissue location contiguous to a PSM could be considered as the critical point of FS analysis and of spared‐NVB management. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Minimally invasive approaches to radical prostatectomy have been touted to lead to superior surgical and functional outcomes with less potential complications despite scant and often conflicting reports in the peer reviewed literature. This review provides evidence that the minimally invasive prostatectomy literature still fails to meet the standards and critical benchmarks necessary for adequate complications reporting. Given our current release on observational studies. Increased effects should be made to standardize all complications and functional outcomes reporting for minimally invasive prostate cancer surgery. To query the minimally invasive urological literature from 2006 to the middle of 2010, focusing on complications and functional outcome reporting in laparoscopic radical prostatectomy (LRP) and robot-assisted LRP (RALP), to see if there has been an improvement in the overall reporting of complications. We performed a Medline search using the Medical Subject Heading terms 'prostatectomy', 'laparoscopy', 'robotics', and 'minimally invasive'. We then applied the Martin criteria for complications reporting to the selected articles. We identified 51 studies for a total of 32 680 patients. When excluding functional outcomes the outpatient complications reporting was 20/51 (39.2%). In all, 35% and 43% of papers did not list any method for recording continence and potency, respectively. A complication grading system was only used in 30 studies (58.8%). Of the 16 papers using a grading scale in 2006-2007, only 31.3% used the Clavien system, compared with 69% from 2008 to the first half of 2010. In all, 27% of papers used some form of risk-factor analysis for complications. Multivariate analysis was used in 43% of papers, 29% looked at body mass index, while one looked at prostate weight, and another age. There has been an overall improvement in complications reporting in the minimally invasive RP literature since 2005. However, most studies still do not fulfil many of the criteria necessary for standardised complication reporting. Functional outcome reporting remains poor and unstandardised. Given our current reliance on observational studies, increased efforts should be made to standardise all complication outcomes reporting. [ABSTRACT FROM AUTHOR]

Study Type - Prognosis (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Prognostic factors such as serum PSA, tumor T stage, and Gleason grading are commonly used to predict disease progression and mortality in prostate cancer and to guide treatment decision-making. These markers are combined to define risk strata that are commonly accepted in practice. Despite the assignment of patients to a specific risk stratum (e.g. intermediate-risk disease), however, within-stratum survival duration varies considerably, suggesting that many other factors, including lymphovascular invasion (LVI) may influence prognosis. LVI is currently a recognized prognostic factor in the management of some cancers (e.g. in early-stage breast cancer) and prostate cancer is known to spread via lymphatic channels. Furthermore, the reporting of microscopic lymphovascular invasion is now considered part of the standard pathologic report of prostatectomy specimens. Nevertheless, scientific studies in this area have produced conflicting conclusions regarding the utility of LVI as a prognostic indicator in prostate cancer. This paper provides a comprehensive review and synthesis of the recent literature. Although a number of studies examining the role of LVI as an independent prognostic factor for biochemical recurrence in prostate cancer have been reported, the characteristics, quality and results of these studies vary considerably. The value of using LVI as a prognostic factor in prostate cancer remains unclear. This study provides a systematically-performed synthesis of the results of recent research including lymphovascular invasion (LVI) in the multivariate analyses of potential prostate cancer prognostic factors. Not only do we report on the results of these studies, we assess the heterogeneity of the study populations, disease characteristics, and quality of the studies. Ultimately, we determined that meta-analysis of the existing data is not possible, and thus, there is no 'best estimate' of the strength of association between LVI status and disease recurrence after prostatectomy. Most studies, but not all, reveal a weak or statistically insignificant association between LVI status and recurrence. We therefore conclude with a recommendation to clinicians that they should not overweight the importance of LVI status on clinical prognostication. The use of LVI status as a strong predictor of clinical outcomes is not recommended. OBJECTIVES To synthesize the results of studies including lymphovascular invasion (LVI) in the multivariate analyses of potential prostate cancer prognostic factors., To determine the role of LVI as an independent prognostic factor for biochemical recurrence in prostate cancer., PATIENTS AND METHODS We performed a comprehensive systematic literature review of studies examining the association between LVI in prostatectomy specimens and prostate cancer recurrence., Ovid MEDLINE, Embase, Web of Knowledge, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects (DARE) and Google Scholar were searched from January 2000 to February 2009., The primary outcome of interest was biochemical recurrence measured by serum prostate specific antigen (PSA)., RESULTS One thousand two hundred and forty-eight papers met our search criteria. Of these, 19 articles meeting our selection criteria reported results of a multivariate analysis to evaluate LVI as an independent prognostic factor of biochemical recurrence., Eleven (58%) of these studies concluded that LVI was an independent prognostic factor., Significant heterogeneity in the study population, disease characteristics and quality of the studies prevented meta-analysis of the results., In the nine studies in which the magnitude of independent association of LVI with recurrence was reported, it ranged from an odds ratio or relative risk of 1.37 to 4.39., CONCLUSIONS The existing literature is conflicting and of insufficient homogeneity to definitively establish LVI as an important independent prognostic factor of biochemical recurrence in prostate cancer prostatectomy specimens., Additional adequately powered studies are required to determine the clinical value of reports of LVI involvement., In the meantime, the use of LVI status as an independent prognostic factor for clinical prognostication and medical decision making is not recommended. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Penile shortening after total prostatectomy has been consistently reported, but most studies are small. BAUS has incorporated penile shortening into their patient information leaflets, but claims it is attributable to an anatomical alteration alone. No other organization even mentions penile shortening in their advice. Our study shows that a true, and at least partially reversible, penile shortening occurs in a significant proportion of patients after total prostatectomy. The cause of the shortening is largely physiological and interlinked with the processes leading to erectile dysfunction. OBJECTIVE To establish an evidence base to guide consenting for treatment of organ-confined prostate cancer with regard to penile shortening., MATERIALS AND METHODS We performed literature searches using the EMBASE, MEDLINE, AHMED and PsycINFO databases up to October 2011, looking for articles relating to surgical treatment of prostate cancer and penile shortening and articles relating to radiotherapy for prostate cancer and penile shortening. We also looked at further references in the papers identified., RESULTS We found 16 original papers and three review articles with measurements of penile shortening after total prostatectomy (TP)., Penile shortening was generally considered in conjunction with erectile dysfunction (ED)., Three further articles address psychological and consent issues., We found two articles regarding penile shortening after radiotherapy for prostate cancer., CONCLUSIONS There is no doubt that TP leads to penile shortening in some patients, but the mechanism remains debatable., Given current evidence, it is likely that several factors contribute and early penile rehabilitation for ED, by any method, appears to positively influence the changes leading to penile shortening., We advise explicit mentioning of penile shortening in the consent process for TP and potentially also for radiotherapy for prostate cancer. We also advise early penile rehabilitation to improve the patient's own body image and, in turn, quality of life, even in patients who do not seek treatment specifically for ED. The choice of treatment method should be left to the patient. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and the safety of applying chitosan membrane (ChiMe) on the neurovascular bundles (NVBs) after nerve-sparing robot-assisted radical prostatectomy (NS-RARP). The secondary aim of the study was to report preliminary data and in particular potency recovery data., Patients and Methods: This was a single-centre, single-arm prospective study, enrolling all patients with localised prostate cancer scheduled for RARP with five-item version of the International Index of Erectile Function scores of >17, from July 2015 to September 2016. All patients underwent NS-RARP with ChiMe applied on the NVBs. The demographics, perioperative, postoperative and complications data were evaluated. Potency recovery data were evaluated in particular and any sign/symptom of local allergy/intolerance to the ChiMe was recorded and evaluated., Results: In all, 140 patients underwent NS-RARP with ChiMe applied on the NVBs. Applying the ChiMe was easy in almost all the cases, and did not compromise the safety of the procedure. None of the patients reported signs of intolerance/allergy attributable to the ChiMe and potency recovery data were encouraging., Conclusion: In our experience, ChiMe applied on the NVBs after NS-RARP was feasible and safe, without compromising the duration, difficulty or complication rate of the 'standard' procedure. No patients had signs of intolerance/allergy attributable to the ChiMe and potency recovery data were encouraging. A comparative cohort would have added value to the study. The present paper was performed before Conformité Européene (CE)-mark achievement., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

To critically review conceptual frameworks for available patient-reported outcome (PRO) questionnaires in men having radical prostatectomy (RP), psychometrically evaluate each questionnaire, and identify whether each is appropriate for use at the level of the individual patient. We searched PubMed, the Reports and Publications database of the University of Oxford Patient-Reported Outcomes Measurement Group and the website of the International Consortium for Health Outcomes Measurement (ICHOM) for psychometric reviews of prostate cancer-specific PRO questionnaires. From these we identified relevant questionnaires and critically appraised the conceptual content, guided by the Wilson and Cleary framework and psychometric properties, using well established criteria. The searches found four reviews and one recommendation paper. We identified seven prostate cancer-specific PROs: the Expanded Prostate Cancer Index Composite-26 (EPIC-26), Expanded Prostate Cancer Index Composite-50 (EPIC-50), University of California-Los Angeles Prostate Cancer Index (UCLA-PCI), Functional Assessment of Cancer Therapy - Prostate Cancer Subscale (FACT-P PCS), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - prostate specific 25-item (EORTC QLQ-PR25), Prostate Cancer - Quality of Life (PC-QoL), and Symptom Tracking and Reporting (STAR). Six out of seven measures purported to measure health-related quality of life (HRQL), but items focused strongly on urinary and sexual symptoms/functioning. The remaining questionnaire (STAR) claimed to assess functional recovery after RP. The psychometric evidence for these questionnaires was incomplete and variable in quality; none had evidence that they were appropriate for use with individual patients. Several questionnaires provide the basis of measures of urinary and/or sexual symptoms/functioning. Further work should explore other aspects of HRQL that are important for men having RP. Further psychometric work is also needed to determine whether they can be used at the individual level., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

What's known on the subject? and What does the study add? Prostate cancer is a significant cause of mortality among men. A number of prognostic instruments exist to predict the risk of recurrence among patients with localised prostate cancer. This systematic review examines the totality of evidence in relation to the predictive value of the CAPRA clinical predication rule by combining all studies that validate the rule., Objectives To perform a systematic review with meta-analysis that assesses the 3- and 5-year predictive value of the CAPRA rule, a clinical prediction rule derived to predict biochemical-recurrence-free survival in men with localized prostate cancer after radical prostatectomy., To examine the predictive value of the CAPRA rule at 3 and 5 years stratified by risk group (0-2 low risk, 3-5 intermediate risk, 6-10 high risk)., Patients and Methods A systematic literature search was performed to retrieve papers that validated the CAPRA score., The original derivation study was used as a predictive model and applied to all validation studies with observed and predicted biochemical-recurrence-free survival at 3 and 5 years stratified by risk group (0-2 low, 3-5 intermediate, 6-10 high)., Pooled results are presented as risk ratios ( RRs) with 95% confidence intervals, in terms of over-prediction ( RR > 1) or under-prediction ( RR < 1) of biochemical-recurrence-free survival at 3 and 5 years., A chi-squared test for trend was computed to determine if there was a decreasing trend in survival across the three CAPRA risk categories., Results Seven validation studies (n = 12 693) predict recurrence-free survival at 5 years after radical prostatectomy. The CAPRA score significantly under-predicts recurrence-free survival across all three risk strata (low risk, RR 0.94, 95% CI 0.90-0.98; intermediate risk, RR 0.94, 95% CI 0.89-0.99; high risk, RR 0.72, 95% CI 0.60-0.85)., Data on six studies (n = 6082) are pooled to predict 3-year recurrence-free survival. The CAPRA score correctly predicts recurrence-free survival in all three groups (low risk, RR 0.98, 95% CI 0.95-1.00; intermediate risk, RR 1.03, 95% CI 0.99-1.08; high risk, RR 0.87, 95% CI 0.73-1.05)., The chi-squared trend analysis indicates that, as the trichotomized CAPRA score increases, the probability of survival decreases (P < 0.001)., Conclusions The results of this pooled analysis confirm the ability of the CAPRA rule to correctly predict biochemical-recurrence-free survival at 3 years after radical prostatectomy., The rule under-predicts recurrence-free survival 5 years after radical prostatectomy across all three strata of risk. [ABSTRACT FROM AUTHOR]

In a large urological oncology section this month the topics of cancer of the prostate, bladder, kidney and testis are covered. To mention but a few of these, authors from New York report that the time from biopsy to surgery in the case of prostate cancer did not influence the probability of biochemical recurrence for men who had a radical prostatectomy within a year of diagnosis. A paper from Boston reports several pregnancies which occurred after brachytherapy for prostate cancer. Incidentally, there is a letter to the Editor at the end of this month's issue, from a UK author, which deals with the same topic. There are two papers from the USA presenting data on the use of nilutamide in hormone-refractory prostate cancer, and a third from Japan using flutamide in the same setting. A report from New York correlates urine cytology findings before and after flexible cystoscopy, finding that cytology immediately after flexible cystoscopy correlates well with that before cystoscopy. OBJECTIVE To evaluate whether the time from biopsy to radical prostatectomy (RP) predicts the biochemical recurrence (BCR) after RP, as men diagnosed with clinically localized prostate cancer have several available treatment options and investigating these alternatives may delay the initiation of definitive therapy. PATIENTS AND METHODS We identified 3969 consecutive patients who had RP for clinically localized prostate cancer from 1987 to 2002; those eligible for the study had RP within a year of diagnosis. The interval between biopsy and RP was analysed both as a continuous and as a dichotomous variable (divided at 3 months). Multivariate analysis was used to evaluate the impact of time to RP on BCR. Subsets were also analysed for the effect of time to RP in patients considered to be at high risk of recurrence, with group 1 having a prostate specific antigen (PSA) level of ≥ 20 ng/mL, a biopsy Gleason score of ≥ 8, or clinical stage ≥ T2c; and group 2 assessed as having a >40% probability of BCR using a preoperative nomogram. RESULTS In all, 3149 patients met the inclusion criteria and had a mean (interquartile range) follow-up after RP of 5.4 (2.2–7.9) years. Multivariate analysis showed that the year of biopsy, PSA level before biopsy, clinical stage and biopsy Gleason score (all P < 0.001) were significantly associated with BCR after RP. The time to RP, treated either as a continuous variable ( P = 0.252) or when categorized at 3 months ( P = 0.939), failed to predict BCR. Further, the time to RP was not an independent predictor of BCR for patients at high risk of recurrence in group 1 ( P = 0.147) or group 2 ( P = 0.548). CONCLUSIONS The time from biopsy to RP did not influence the probability of BCR for men who had RP within a year of diagnosis, even for those considered to be at high risk of BCR. Instead, the clinical and pathological features of the cancer provided the best estimate of the risk of BCR. [ABSTRACT FROM AUTHOR]

In the first paper in this section, authors from the Mayo Clinic describe their experience and 15-year outcomes in the controversial subject of radical prostatectomy in patients with clinical T3 prostate cancer. The findings were interesting in many respects, but the authors concluded that radical prostatectomy as part of multimodal treatment for patients with clinical T3 disease offers cancer control and good survival rates.There follows a series of papers on both prostate cancer and bladder cancer, but the final paper in this section from the UK attempts to define the accuracy of urologists and oncologists in assessing patient life-expectancy. Using various methods they found that, rather disappointingly, doctors were poor at predicting 10-year survival, leading to the possible outcome that some patients may be denied treatment after a pessimistic assessment of life-expectancy.To report a long-term experience with extirpative surgery in patients presenting with locally advanced (cT3) prostate cancer, as the best management of such patients remains a problem.In a single-institution retrospective study identifying 5652 men who had radical prostatectomy (RP) for histologically confirmed prostate cancer since the advent of prostate-specific antigen (PSA) testing (1987–97), 15% (842) had RP for cT3 disease. The median follow-up of these men was 10.3 years. Cancer-specific, overall and disease-free survival was plotted and compared with those of patients having RP for cT2 disease during the same period. Perioperative morbidity, continence and erectile function rates were examined, with a multivariate analysis for risk factors of disease recurrence.Freedom from local or systemic disease at 5, 10, and 15 years after RP for cT3 disease was 85%, 73% and 67%; the respective cancer-specific survival rates were 95%, 90% and 79%. Significantly many men who did not receive neoadjuvant therapy (27%) were clinically over-staged (pT2) and most men with pT3 disease (78%) received adjuvant therapy. The mean time to adjuvant therapy after RP was not significantly different between men with cT3 and cT2 disease (4.0 and 4.3 years). Pathological grade (≥7), positive surgical margins, and nondiploid chromatin were all independently associated with a significant risk for clinical disease recurrence, while preoperative PSA level had little effect on outcome. Complications and continence rates after RP in patients with cT3 mirrored those in patients with cT2 disease.Significantly many patients with cT3 prostate cancer are overstaged (pT2) in the PSA era. RP as part of a multimodal treatment strategy for patients with cT3 disease offers cancer control and survival rates approaching those achieved for cT2 disease. Pathological grade, ploidy and margin status are all significant predictors of outcome after RP. Complications and incontinence rates in patients with cT3 disease mirror those after RP for cT2 disease. [ABSTRACT FROM AUTHOR]

Authors from Miami describe their technique of concurrent radical retropubic prostatectomy and inguinal hernia repair through a modified Pfannenstiel incision. They found this approach to be ideal for performing both operations at the same time, allowing a tension-free mesh hernia repair with excellent exposure of the pelvic structures. An interesting paper from authors in New York reviews patients who had both bladder and lung cancer. Their findings are important in terms of a potential guideline to urologists who have patients with these conditions, and are, for example, faced with the decision as to whether they should operate on someone who has a history of lung cancer but now has bladder cancer. In another paper from the New York area, authors describe the effect on morbidity and mortality of bone metastasis in patients with RCC. They found the effect to be considerable, and suggest a possible role for bisphosphonates. To describe a technique for concurrent radical retropubic prostatectomy (RRP) and inguinal hernioplasty, using a modified Pfannenstiel incision. RRP is usually done through a midline lower abdominal incision but some patients with localized prostate cancer have an inguinal hernia. Concurrent inguinal hernia repair at the time of RRP with the usual method is only possible by either a preperitoneal mesh repair or formal hernioplasty, requiring an additional incision(s). A 10–12 cm Pfannenstiel incision is made along the pubic hairline centred over the pubic symphysis, and a ‘Y’-shaped incision in the rectus sheath. The rectus muscle is split vertically along the midline, followed by RRP. After removing the prostate and completing the anastomosis, the surgeon identifies the inguinal canal along the inferior and lateral aspect of the transverse incision and uses a formal tension-free hernioplasty with a 3 × 5 cm polypropylene mesh. We used this technique in fifteen concurrent inguinal hernioplasties (two bilateral hernias and thirteen unilateral) at the time of RRP, with no additional incisions, using the formal tension-free Lichtenstein technique. One patient with bilateral hernias had a right indirect inguinal hernia, and all the remaining men had a direct inguinal hernia. All patients were discharged 2 days after surgery, with no complications associated with the procedure and no recurrences; however, the follow-up was short (mean 5.5 months). A modified Pfannenstiel incision is ideal for concurrent RRP and inguinal hernioplasty, providing excellent exposure of the pelvic structures and allowing the surgeon to use a formal tension-free mesh hernioplasty through the same incision. Wound healing and cosmetic results are excellent. [ABSTRACT FROM AUTHOR]

Once again, there have been a significant number of papers on prostate cancer submitted and accepted, and this is reflected in that six of the nine papers published in this section this month relate to this disease. Many aspects of the condition are discussed. Readers may be interested learn of the severe complications associated with brachytherapy which the authors from Miami have described, and how they dealt with them. This type of therapy will continue to be reported in this journal, with several comments appearing in subsequent editions. Two papers appear on favourite topics in bladder cancer; what we can expect from T1G3 tumours, by authors from France, and the morbidity associated with extended lymphadenectomy, by authors from Austria and Italy. Finally, the authors from Paris with very extensive experience in laparoscopy describe this technique in the treatment of T1 renal cancer. To report a retrospective chart review of patients who developed recto-urethral fistula (RUF) or several bladder neck contracture (BNC) recurrences after brachytherapy for treating localized prostate cancer. In the past 3 years 18 patients with devastating complications after prostate brachytherapy were referred to our centre (RUF in 11, BNC in seven; mean age 63 years, range 60–81). All patients with RUF initially underwent diverting colostomy (six cystoprostatectomy with closure of the fistula, omental interposition and urinary diversion; one prostatectomy, bladder neck closure, fistula closure with omentum flap and continent vesicostomy). Three patients had the fistula closed with gracilis muscle flap using the York-Mason approach (one had a bladder neck closure and suprapubic tube; one elected to have no treatment). All patients with BNC had received three or more procedures to resect or incise their contracture. Four had diversion with a catheterizable segment, two used an indwelling Foley catheter and one uses intermittent catheterization. All six patients who had cystoprostatectomy with urinary diversion have had no recurrence of their RUF. All three treated with the York-Mason procedure healed well. One developed recurrent prostate adenocarcinoma and two a secondary neoplasia in the prostate or rectum (leiomyosarcoma and neuroendocrine, respectively). The enterocystoplasty patient developed sepsis after colostomy reversal and subsequently died. In those patients with BNC, the four who underwent urinary diversion fared well; two tolerate the indwelling catheter poorly, and the seventh uses intermittent catheterization with occasional difficulty. Brachytherapy with or without external irradiation can be associated with severe complications. RUF managed with aggressive anterior pelvic exenteration and urinary diversion can be associated with excellent results. The York-Mason procedure in patients with an adequate urinary continence mechanism and bladder dynamics may provide good functional results. The presence of a secondary malignancy in patients deserves further investigation. Many recurrences of a BNC tend be refractory to transurethral resection/incision; indwelling catheters are then poorly tolerated and patients may require a major reconstructive procedure. [ABSTRACT FROM AUTHOR]

It is a reflection of the many manuscripts submitted on urological oncology in general, and prostate cancer in particular, that I am publishing 10 papers in this section this month. Seven of these relate to the latter subject. The authors from the Lahey Clinic describe their technique of radial prostatectomy and include a novel method of posterior bladder plication. They report an early return to continence and conclude that the technique is important in achieving their excellent results. In another study the group from Stockport show that patients often make decisions about types of treatment for prostate cancer having been strongly influenced by their partner, who in turn may have had pre-existing conceptions about this. They recommend early involvement of the partner to help in this very important decision-making. The two papers on bladder cancer describe possible prognostic factors, both clinical and laboratory-based, from a large experience in Hamburg and Mansoura. OBJECTIVE To analyse the incidence of incontinence after radical retropubic prostatectomy (RRP) and the time to return of continence, using an RRP technique including a novel posterior bladder plication PATIENTS AND METHODS We retrospectively reviewed the medical records of 200 consecutive patients who underwent RRP between September 1995 and February 1997, by one surgeon, at our institution. Patient characteristics including age, preoperative prostate-specific antigen (PSA) level and Gleason grade, were assessed. Continence was assessed before and after RRP by either a third-party patient interview or a prospective validated questionnaire. Continence was defined as not requiring the use of any sanitary pads or diapers. The continence rate was determined immediately after catheter removal, and at 3, 6, 12 and 15 months after RRP. RESULTS The mean age of the patients was 59.4 years, the preoperative PSA level 8.5 ng/mL and the Gleason grade 6.1. The time to continence and percentage of continent patients was 63.5% immediately, 82% at 3 months, 91% at 6 months, and 98.5% at 12 months after RRP. At 15 months, 199 of 200 consecutive patients were continent (99.5%). CONCLUSION With our technique there was an early return to continence and only a minor incontinence rate at 15 months. The cumulative effect of sequential technical manoeuvres in our RRP technique, including posterior bladder plication, is critical for continence after RRP. [ABSTRACT FROM AUTHOR]

Objectives: Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery. These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes., Methods: A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study., Results: Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1-1.76 days and 1-5.5 days, respectively) and blood loss (range 482-780 mL and 227-234 mL, respectively) when compared with the open approach (range 2-8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000-$39,215) than both laparoscopic (range US $740-$29,771) and open radical prostatectomy (range US $1870-$31,518). This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1-1.5 days) and length of surgery (range 102-360 min) are unable to compensate for the excess costs. Robotic surgery may require a smaller learning curve (20-40 cases) although the evidence is inconclusive., Conclusions: Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve. Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs. Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery., (© 2012 BJU INTERNATIONAL.)

What's known on the subject? and What does the study add? Very few comparative studies to date evaluate the results of treatment options for prostate cancer using the most sensitive measurement tools. PSA has been identified as the most sensitive tool for measuring treatment effectiveness. To date, comprehensive unbiased reviews of all the current literature are limited for prostate cancer. This is the first large scale comprehensive review of the literature comparing risk stratified patients by treatment option and with long-term follow-up. The results of the studies are weighted, respecting the impact of larger studies on overall results. The study identified a lack of uniformity in reporting results amongst institutions and centres. A large number of studies have been conducted on the primary therapy of prostate cancer but very few randomized controlled trials have been conducted. The comparison of outcomes from individual studies involving surgery (radical prostatectomy or robotic radical prostatectomy), external beam radiation (EBRT) (conformal, intensity modulated radiotherapy, protons), brachytherapy, cryotherapy or high intensity focused ultrasound remains problematic due to the non-uniformity of reporting results and the use of varied disease outcome endpoints. Technical advances in these treatments have also made long-term comparisons difficult. The Prostate Cancer Results Study Group was formed to evaluate the comparative effectiveness of prostate cancer treatments. This international group conducted a comprehensive literature review to identify all studies involving treatment of localized prostate cancer published during 2000-2010. Over 18,000 papers were identified and a further selection was made based on the following key criteria: minimum/median follow-up of 5 years; stratification into low-, intermediate- and high-risk groups; clinical and pathological staging; accepted standard definitions for prostate-specific antigen failure; minimum patient number of 100 in each risk group (50 for high-risk group). A statistical analysis (standard deviational ellipse) of the study outcomes suggested that, in terms of biochemical-free progression, brachytherapy provides superior outcome in patients with low-risk disease. For intermediate-risk disease, the combination of EBRT and brachytherapy appears equivalent to brachytherapy alone. For high-risk patients, combination therapies involving EBRT and brachytherapy plus or minus androgen deprivation therapy appear superior to more localized treatments such as seed implant alone, surgery alone or EBRT. It is anticipated that the study will assist physicians and patients in selecting treatment for men with newly diagnosed prostate cancer., (© 2012 The Authors; BJU International © 2012 BJU international.)

Unlabelled: What's known on the subject? and What does the study add? Prognostic tools, such as the Cancer of the Prostate Risk Assessment (CAPRA) score and the 1998 Kattan and 2006 Stephenson nomograms, predicting biochemical recurrence after radical prostatectomy are widely used for treatment decision making and counselling patients. However, tools derived in certain cohorts tend to perform less well when they are applied to populations that are dissimilar in terms of population or disease characteristics, health systems or treatment practices. Some of the loss in accuracy of a prognostic tool is a consequence of unknown factors and hence the performance of a tool when applied to a different population is unknown and largely unpredictable. This study validates these widely used tools in South Australian patients treated at three public hospitals. All three tools discriminated well according to risk of recurrence in these patients. However, when compared against observed rates of recurrence, it was found that predictions of recurrence varied widely between the three tools, suggesting that their use in counselling patients on such risk may not be appropriate. Interestingly, the oldest of the three tools (Kattan 1998) was the best predictor of absolute risk of recurrence. In the paper, this is linked to later adoption of updated Gleason grading, among other factors., Summary: In many countries, prognostic tools, which draw on the experience of thousands of patients with cancer, are used to predict cancer outcomes, but accuracy varies. This paper compares the accuracy of three widely used tools predicting prostate cancer recurrence after surgery in Australian patients. The results show that all tools were good at predicting which patients were most likely to experience recurrence and which were least. However, prediction of absolute risk varied and the oldest tool was the most accurate., Objective: • To compare performance of the CAPRA score and two commonly used risk assessment nomograms, the 1998 Kattan and the 2006 Stephenson, in an untested Australian cohort., Patients and Methods: • We present data on 635 men from the South Australian Prostate Cancer Clinical Outcomes Database who underwent radical prostatectomy between January 1996 and May 2009 and had all required variables for predicting biochemical recurrence (BCR). • BCR was defined as prostate-specific antigen ≥ 0.2 ng/mL or secondary treatment for a rising prostate-specific antigen. • Accuracy was evaluated using Harrell's concordance index, plotting calibration curves, and constructing decision analysis curves., Results: • Concordance indices were high for all three tools: 0.791, 0.787 and 0.744 for the 2006 Stephenson nomogram, CAPRA score and 1998 Kattan nomogram respectively. •  At 3 years, calibration of the tools (agreement between predicted and observed BCR-free probability) was close to ideal for the 1998 Kattan nomogram, whereas the 2006 Stephenson model underestimated and the CAPRA model overestimated BCR-free probability. • The 1998 Kattan and 2005 CAPRA tools performed better than the 2006 Stephenson nomogram across a wide range of threshold probabilities using decision curve analysis., Conclusion: • All three tools discriminate between patients' risk effectively. • Absolute estimates of risk are likely to vary widely between tools, however, suggesting that models should be validated and, if necessary, recalibrated in the population to which they will be applied. • Recent development does not mean a nomogram is more accurate for use in a particular population., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

In this section, authors from New York give their views on the various neuroprotective strategies for patients having a radical prostatectomy, such as the use of nerve grafts and other approaches. A joint study from Korea, the USA, Canada and the UK is presented in a paper on the importance of patient perception in the clinical assessment and management of BPH. There is also a review of robotic urological surgery. Finally, authors from New York give a review on the life of Isaac Newton. This is a new historical review in the journal, but one that will be of general interest.

Unlabelled: The authors from the Vattikuti Institute in the USA report a prospective comparison of radical prostatectomy and robot-assisted prostatectomy. They found that the robot-assisted procedure was safer, and yielded favourable oncological and functional results. They also present work in association with the Department of Urology in Mansoura into robot-assisted radical cystoprostatectomy and urinary diversion, and point out the advantages and disadvantages associated with performing the most complex types of urinary diversion. There is also an interesting paper relating to the association between sexual factors and prostate cancer, from authors in institutions in Australia, New Zealand and Italy. They found that in a case-control study of men aged <70 years, ejaculatory frequency was negatively associated with the risk of prostate cancer. Technology has made many contributions to the management of urological patients. The classic example is that of urinary stone management. Authors from the USA evaluated cyroablation of renal carcinoma in patients with solitary kidneys. They are encouraged by their results and suggest that there is merit in this treatment, but indicate the need for a longer follow-up., Objective: To prospectively compare standard radical retropubic prostatectomy (RRP) and the robotically assisted Vattikuti Institute prostatectomy (VIP) in the management of localized prostate cancer., Patients and Methods: The study was a single-institution, prospective, unrandomized comparison of histopathological, and functional outcomes, at baseline and during and after surgery, in 100 patients undergoing RRP and 200 undergoing VIP., Results: While the variables before surgery, the operative duration (163 vs 160 min) and pathological stages were comparable, there were significant differences in the measured outcomes. The blood loss was 910 and 150 mL for RRP and VIP, respectively, and transfusion was greater after RRP (67% vs none; both P < 0.001). There were four times as many complications after RRP (20% vs 5%, P < 0.05), the haemoglobin level at discharge was lower (100 vs 130 g/L, P < 0.005) and the hospital stay longer (3.5 vs 1.2 days; P < 0.05). Most (93%) of VIP and none of the RRP patients were discharged within 24 h (P < 0.001); the duration of catheterization was twice as long after RRP (15.8 vs 7 days; P < 0.05). Positive margin was more frequent after RRP (23% vs 9%, P < 0.05). After VIP, patients achieved continence and return of erections more quickly than after RRP (160 vs 44, and 180 vs 440 days, both P < 0.5). The median return to intercourse was 340 days after VIP but after RRP half the patients have as yet not resumed intercourse at 700 days (P < 0.05)., Conclusions: The VIP procedure appears to be safer, less bloody and requires shorter hospitalization and catheterization. The oncological and functional results were favourable in patients undergoing VIP.

We previously reviewed different technical modifications and improvements in apical dissection in radical retropubic prostatectomy which have a considerable effect in optimizing the results. This second paper focuses on the vesico-urethral anastomosis and aspects of nerve-sparing prostatectomy.

An introduction is presented in which the editor discusses various reports within the issue on topics including the radiation for prostate cancer, radical prostatectomy and the launch of the journal's web portal.

The article presents the author's insights on the paper by S. Pridgeon and colleagues which examines the incidence of lower limb compartment syndrome in Great Britain for patients experiencing robot-assisted radical prostatectomy (RARP). The author notes the surgical procedure described in the paper, emphasizing the significance of operative duration in robot-assisted surgery. Moreover, the author cites the involvement of primary surgeons in the robotic fellowship.

This is a comment moderated paper. Please go to for further details. OBJECTIVE To review the literature on racial variation in the pattern of care (PoC) and quality of care (QoC) for prostate cancer, as there are known racial disparities in the incidence and outcomes of prostate cancer. While there are some biological explanations for these differences, they do not completely explain the variation. Differences in the appropriateness and QoC delivered to men of different racial groups may contribute to disparities in outcome. METHODS We searched the USA National Library of Medicine PubMed system for articles pertaining to quality indicators in prostate cancer and racial disparities in QoC for prostate cancer. RESULTS While standards for appropriate treatment are not clearly defined, racial variation in the PoC has been reported in several studies, suggesting that African-American men may receive less aggressive treatment. There are validated QoC indicators in prostate cancer, and researchers have begun to evaluate racial variation in adherence to these quality indicators. Further quality comparisons, particularly in structural measures, may need to be performed to fully evaluate differences in QoC. CONCLUSIONS There is mounting evidence for racial variation in the PoC and QoC for prostate cancer, which may contribute to observed differences in outcome. While some of the sources of racial variation in quality and outcome have been identified through the development of evidence-based guidelines and validated quality indicators, opportunities exist to identify, study and attempt to resolve other components of the quality gap. [ABSTRACT FROM AUTHOR]

In an interesting study, authors from Austria attempted to elucidate how often detrusor overactivity persists after TURP, and if perfusion of the lower urinary tract influences the outcome. They found that increased vascular resistance of the bladder vessels leads to reduced perfusion, and provide a possible explanation for the persistent symptoms. In a multicentre, community-based randomized study conducted in the USA and UK, the transdermal oxybutynin system improved the quality of life in adults with overactive bladder. The final paper in this section is from Turkey, presenting the long-term results of transurethral vaporisation using plasmakinetic energy. OBJECTIVES To elucidate, in patients with benign prostatic hyperplasia (BPH), how often detrusor overactivity (DOA) is persistent after transurethral resection of the prostate (TURP) and if perfusion of the lower urinary tract influences postoperative outcomes. PATIENTS AND METHODS Fifty men with urodynamically confirmed DOA and bladder outlet obstruction due to BPH had a TURP. Before and 1 year after TURP the International Prostate Symptom Score (IPSS), quality of life (QoL) score, prostate-specific antigen (PSA) level and total prostatic volume (TPV) were evaluated. Also, the lower urinary tract was evaluated using pressure-flow studies and transrectal colour Doppler ultrasonography to assess the vascular resistive index (RI) as a variable of the perfusion of the lower urinary tract. RESULTS After TURP the IPSS, QoL score, PSA level and TPV decreased. Cystometric measurements showed that in 15 (30%) patients DOA was persistent after TURP. The mean (sd) maximum urinary flow rate increased from 9.20 (4.03) to 15.98 (4.62) mL/s and postvoiding residual urine volumes decreased from 109.38 (73.71) to 29.24 (45.00) mL. When men with persistent DOA (15 patients; group 1) were compared with those with no DOA after TURP (35; group 2) there was a statistically significantly higher RI of the bladder vessels in group 1, at 0.86 (0.068) than in group 2, at 0.68 ( 0.055) ( P < 0.001). CONCLUSIONS Persistent DOA in men after TURP seems to be associated with increased vascular resistance of the bladder vessels with subsequent reduced perfusion and hypoxia. [ABSTRACT FROM AUTHOR]

Authors from New York present their experience with exclusively anteriorly located prostate cancers and compare them to those located only in the posterior part of the prostate. In this very large series, they found that the former group had lower Gleason grades and lower rates of extraprostatic extension. In a paper from Cleveland, USA, the authors evaluate the rates of local and systemic progression, recurrence-free survival and overall survival for patients with bladder carcinoma after limited pelvic lymph node dissection. In keeping with other reports where extended pelvic lymph node dissection was used, these authors reported decreased rates of survival with the limited dissection. OBJECTIVE To identify the clinical characteristics of anterior prostate cancers (APCs) and to compare these with posterior prostate cancers (PPCs). PATIENTS AND METHODS We reviewed 1290 consecutive open and laparoscopic radical prostatectomies (RPs) at the authors’ institution from January 2000 to March 2004. Prostates were processed using a whole-mount technique. Each surgical specimen was reviewed by one pathologist, and tumour areas were marked, measured and mapped. Positive surgical margins (PSMs) were defined as the presence of cancer cells at the inked surface of the specimen. Specimens were then categorized by the location of their dominant tumour, i.e. pure anterior, anterior > posterior, posterior > anterior, or pure posterior. We compared the clinical and pathological characteristics of 259 patients in the pure-anterior group with the 594 in the pure-posterior group. RESULTS Before RP, APCs had a significantly lower biopsy Gleason score (78% vs 68% with Gleason 4–6), fewer mean biopsy cores positive (2.0 vs 2.6), a smaller median percentage of positive cores (17% vs 26%), lower clinical stage (T1 in 79% vs 62%), and higher progression-free probability estimated by preoperative nomogram (86% vs 84%) than PPCs. Patients with APCs also had more previous negative biopsy sessions. The pathological analysis of RP specimens showed that those with APCs had higher tumour volume (1.6 vs 0.83 mL) and had a higher PSM rate (12% vs 7%) than those with PPCs, despite specimens with PPCs having higher rates of extraprostatic extension (10% vs 19%). CONCLUSIONS APCs have lower Gleason grade and lower rates of extraprostatic extension, yet patients with anterior tumours have higher overall tumour volumes and higher PSM rates. Because current tools for detecting and staging prostate cancer can underestimate the extent of anterior prostate disease, improved methods are needed for localizing and characterizing anterior cancers. [ABSTRACT FROM AUTHOR]

There are several papers in this section on various aspects of prostate cancer: predictive models, robotic radical prostatectomy in large glands, PSA distribution, bicalutamide and PIN, and finally the clinical characteristics of bladder cancer in patients previously treated with irradiation for prostate cancer. There are also several manuscripts on renal, testis and penile cancer. A wide variety of topics, from authors of many nationalities, maintaining the unique internationalism of the BJU International. [ABSTRACT FROM AUTHOR]

Authors from the USA sought to establish the relationship between tumour volume, pathological stage and outcomes after radical prostatectomy. In a large series of patients they found that tumour volume was correlated directly with pathological stage, and that it was independently correlated with PSA recurrence. The authors suggested that tumour volume had a potential use for prognostication in patients undergoing radical prostatectomy. Two papers, one from the USA and one from Germany, advise a re-staging TUR in patients with superficial bladder cancer who are at high risk of early tumour progression. In a large series of patients they found that residual tumour after initial resection was commoner than might be expected, and that the second resection indicated the way to earlier radical treatment and a better prognosis. OBJECTIVE To establish the relationship between tumour volume (TV), pathological stage and outcome after radical prostatectomy (RP), as TV is theoretically an important variable in prostate cancer pathology, but to date it has not been routinely reported and its independent prognostic significance is not well defined. PATIENTS AND METHODS The study included 431 consecutive patients undergoing RP for clinically localized cancer, from January 2000 to January 2002, who had a pathological examination of totally submitted whole-mount processed RP specimens. In addition to Gleason grade, tumour stage and margin assessment by standard techniques, TV was determined by digital planimetry. The total TV or index TV, for cases with obvious discrete separate tumours, were correlated with pathological stage and prostate-specific antigen (PSA) recurrence. RESULTS The mean (range) follow-up was 25.4 (6–51) months, and the mean TV for all patients was 3.28 (0.4–38.8) mL. There was a direct correlation between TV and pathological stage ( P < 0.001). The TV for organ-confined and extraprostatic disease was 2.09 and 6.02 mL, respectively ( P < 0.001). In a multivariate analysis, TV was an independent predictor of PSA recurrence ( P = 0.04). The mean TV for patients with PSA recurrence vs no recurrence was 6.8 and 2.6 mL, respectively ( P < 0.001). CONCLUSION TV correlates directly with pathological stage in RP specimens; furthermore, it is independently correlated with PSA recurrence. TV has potential use for prognostication in patients undergoing RP, and may be combined with other well established clinical variables to aid in predicting outcomes. [ABSTRACT FROM AUTHOR]

Objective: To report open‐label phase data from a recent randomized controlled trial (RCT), after previous data from that study showed improved penile length and erectile function among post‐prostatectomy men treated with Restorex penile traction therapy (RxPTT). Materials and Methods: An RCT (NCT05244486) was performed to evaluate RxPTT vs no treatment (Tx) for 5 months, which was followed by a 3‐month open‐label phase. Men were stratified based on as‐treated data: Group 1 = No Tx; Group 2 = No Tx → Tx; Group 3 = Tx → No Tx; Group 4 = Tx. Assessments included stretched penile length and standardized (International Index of Erectile Function [IIEF]) and non‐standardized questionnaires. Results: A total of 82 men were enrolled (mean age 58.6 years) with 9‐month data available in 45 of the men. Baseline characteristics were similar among the cohorts. Comparing Group 1 and Group 4 (respectively), notable differences included: IIEF Erectile Function domain (IIEF‐EF) score (−8 vs −0.5; P = 0.16), penile length (−0.1 vs +1.7 cm; P < 0.01), intracavernosal injection use (86% vs 14%; P < 0.01), Sexual Encounter Profile (SEP) Question 2 (50% vs 100%; P < 0.01), SEP Question 3 (33% vs 100%; P < 0.01). Men who crossed over to Tx (Group 2) failed to achieve equivalent improvements in length (+0.5 cm) or sexual function (IIEF‐EF score −6) compared to men treated early (Groups 3 and 4). Those who crossed over to no treatment after initial treatment (Group 3) experienced preserved length (+1.8 cm), and erectile function (IIEF‐EF score +0) despite therapy discontinuation. Conclusions: Use of RxPTT beginning 1 month post‐prostatectomy results in improved penile length and erectile function, with benefits maintained after discontinuing therapy. If confirmed, these results represent the first postoperative therapy shown in a RCT to improve erectile function post‐prostatectomy. External validation is warranted. [ABSTRACT FROM AUTHOR]

Objectives To analyse the Australian experience of high-volume Fellowship-trained Laparoscopic Radical Prostatectomy ( LRP) surgeons. Materials and Methods 2943 LRP cases were performed by nine Australian surgeons. The inclusion criteria were a prospectively collected database with a minimum of 100 consecutive LRP cases. The surgeons' LRP experience commenced at various times from July 2003 to September 2009. Data were analysed for demographic, peri-operative, oncological and functional outcomes. Results The mean age of patients were 61.5 years and mean preoperative PSA 7.4 ng/ml. Mean operating time was 168 minutes with conversion to open surgery in 0.5% and a blood transfusion rate of 1.1%. Overall mean length of stay was 2.5 days. 73.6% of pathological specimens were pT2 and 86.3% had Gleason Score >7. Overall positive surgical margins ( PSM) occurred in 15.9% with pT2 PSM 9.8%, pT3a PSM 30.8% and pT3b PSM 39.2%. Mean urinary continence at 12 months was 91.4% (data available from five surgeons). Mean 12 months potency after bilateral nerve spare was 47.2% (data available from four surgeons). Biochemical recurrence occurred in 10.6% (mean follow up 17 months). Conclusion The Australian experience of Fellowship trained surgeons performing LRP demonstrates favourable peri-operative, oncological and functional outcomes in comparison to published data for open, laparoscopic and robotic assisted radical prostatectomy. In our Australian centres, LRP remains an acceptable minimally invasive surgical treatment for prostate cancer despite the increasing use of robotic assisted surgery. [ABSTRACT FROM AUTHOR]

GLO:F02/01jan22:bju15668-fig-0001.jpg PHOTO (COLOR): . gl © istock.com/artisteer The recent UN Climate Change conference (COP26) that took place in Glasgow, Scotland in November has served to focus minds regarding the potential future risks to our planet as a consequence of global warming. Healthcare accounts for nearly 5% of the total global greenhouse gases, giving it the largest carbon footprint of any service sector. [Extracted from the article]

[5] recent critique of the use of CUSUM methods with surgical LC data suggests that industrial LC models have not been applied to full advantage in surgical applications. Assessing the learning curve of single-port robot-assisted prostatectomy In the early stages of surgical innovation, outcomes are influenced by the surgeon's learning curve (LC). [Extracted from the article]

Objective To conduct a systematic review and meta-analysis of artificial urinary sphincter ( AUS) placement after radical prostatectomy ( RP) and external beam radiotherapy ( EBRT). Patients and Methods There were 1 886 patients available for analysis of surgical revision outcomes and 949 for persistent urinary incontinence ( UI) outcomes from 15 and 11 studies, respectively. The mean age ( sd) was 66.9 (1.4) years and the number of patients per study was 126.6 (41.7). The mean ( sd, range) follow-up was 36.7 (3.9, 18-68) months. A systematic database search was conducted using keywords, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA) guidelines. Published series of AUS implantations were retrieved, according to the inclusion criteria. The Newcastle-Ottawa Score was used to ascertain the quality of evidence for each study. Surgical results from each case series were extracted. Data were analysed using CMA® statistical software. Results AUS revision was higher in RP + EBRT vs RP alone, with a random effects risk ratio of 1.56 (95% confidence interval [ CI] 1.02-2.72; P < 0.050; I2 = 82.0%) and a risk difference of 16.0% (95% CI 2.05-36.01; P < 0.080). Infection/erosion contributed to the majority of surgical revision risk compared with urethral atrophy ( P = 0.020). Persistent UI after implantation was greater in patients treated with EBRT ( P < 0.001). Conclusions Men receiving RP + EBRT appear at increased risk of infection/erosion and urethral atrophy, resulting in a greater risk of surgical revision compared with RP alone. Persistent UI is more common with RP + EBRT. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics, which include predicting biochemical recurrence after radical prostatectomy, urine DNA methylation panel and analysis of prostate cancer risk loci from genome-wide association studies (GWAS).

The I BJUI i blogs have often been read more than the articles themselves, bringing immediacy, wider engagement and sensible debate. The I BJUI i is the only surgical journal to be rated in the Altmetric top 50 reaching a score of 1469 [[1]], compared to an average Altmetric score of 3. In this issue of the I BJUI i , we have published the protocol and curriculum development of the SIMULATE study - the world's first and only multi-centre randomised controlled trial of surgical simulation. [Extracted from the article]

In this month's issue of I BJUI i , Herrera-Caceres et al. [[1]] report the results of a retrospective cohort study in 34 patients who underwent salvage radical prostatectomy after focal therapy. This rate is clearly higher than in men undergoing surgery for primary disease; however, it is similar to that in surgery for recurrent disease in other tumour types for which surgery appears always to be associated with worse oncological outcomes. [Extracted from the article]

A letter to the editor is presented in response to the article "Contemporaneous comparison of open vs minimally invasive radical prostatectomy for high-risk prostate cancer," by P. M. Pierorazio and colleagues in the 2013 issue.

GLO:F02/01aug21:bju15538-fig-0001.jpg PHOTO (COLOR): . gl In May 2021, the FDA approved piflufolastat F18 (Pylarify™), an agent that binds to cells that express prostate specific membrane antigen (PSMA) for use in positron emission tomography (PET) scanning. Following a preoperative PET/CT scan using piflufolastat, the patients underwent radical prostatectomy with template pelvic node dissection. [Extracted from the article]

Objectives: To evaluate the impact of intralesional heterogeneity on the performance of multiparametric magnetic resonance imaging (mpMRI) in determining cancer extent and treatment margins for focal therapy (FT) of prostate cancer. Patients and Methods: We identified men who underwent primary radical prostatectomy for organ‐ confined prostate cancer over a 3‐year period. Cancer foci on whole‐mount histology were marked out, coding low‐grade (LG; Gleason 3) and high‐grade (HG; Gleason 4–5) components separately. Measurements of entire tumours were grouped according to intralesional proportion of HG cancer: 0%, <50% and ≥50%; the readings were corrected for specimen shrinkage and correlated with matching lesions on mpMRI. Separate measurements were also taken of HG cancer components only, and correlated against entire lesions on mpMRI. Size discrepancies were used to derive the optimal tumour size and treatment margins for FT. Results: There were 122 MRI‐detected cancer lesions in 70 men. The mean linear specimen shrinkage was 8.4%. The overall correlation between histology and MRI dimensions was r = 0.79 (P < 0.001). Size correlation was superior for tumours with high burden (≥50%) compared to low burden (<50%) of HG cancer (r = 0.84 vs r = 0.63; P = 0.007). Size underestimation by mpMRI was more likely for larger tumours (51% for >12 mm vs 26% for ≤12 mm) and those containing HG cancer (44%, vs 20% for LG only). Size discrepancy analysis suggests an optimal tumour size of ≤12 mm and treatment margins of 5–6 mm for FT. For tumours ≤12 mm in diameter, applying 5‐ and 6‐mm treatment margins would achieve 98.6% and 100% complete tumour ablation, respectively. For tumours of all sizes, using the same margins would ablate >95% of the HG cancer components. Conclusions: Multiparametric MRI performance in estimating prostate cancer size, and consequently the treatment margin for FT, is impacted by tumour size and the intralesional heterogeneity of cancer grades. [ABSTRACT FROM AUTHOR]

Objective: Coronavirus disease‐19 (COVID‐19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. The objective of this work is to develop guidance on criteria for prioritisation of surgery and reconfiguring management pathways for patients with non‐metastatic prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve a low likelihood of coronavirus disease 2019 (COVID‐19) hazard if radical prostatectomy (RP) was to be carried out during the outbreak and whilst the disease is endemic. Methods: We conducted an accelerated consensus process and systematic review of the evidence on COVID‐19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n = 34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second‐ and third‐round surveys were formulated based on the answers and comments from the previous rounds. The Consensus opinion was defined as ≥80% agreement and this was used to reconfigure the prostate cancer pathways. Results: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and measures developed to prevent nosocomial COVID‐19 for patients treated surgically. Consensus was reached on prioritisation criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID‐19 were coined as 'COVID‐19 cold' sites. Conclusion: Reconfiguring management pathways for patients with prostate cancer is recommended if significant delay (>3–6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing RP within an environment with low COVID‐19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Effect of statin use on biochemical outcome following radical prostatectomy," by Chad R. Ritch and colleagues in the 2011 issue.

Abbreviations AUA, American Urological Association; BPH, benign prostatic hyperplasia; CUA Canadian Urological Association EAU European Association of Urology; HRQoL, health-related quality of life; IPSS, International Prostate Symptom Score LUTS lower urinary tract symptoms PtDA patient decision aid PVP photovaporisation SMOG Simple Measure of Gobbledygook TURP transurethral resection of the prostate Introduction There are several surgical options to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). This allows patients to have the chance to explore treatment options not offered by their urologist and at the same time encourages urologists that do not offer all of the presented treatments to use the PtDA effectively, while still educating their patients about all possible options. For one, the Dutch BPH PtDA is not specific to surgical treatments; only four out of the nine surgical treatments described in our PtDA are included in the Dutch PtDA. Acceptability and validation testing will ensure that the finalised PtDA is acceptable with all stakeholders, including patients and urologists, and is improving quality of decision-making by BPH surgery patients. [Extracted from the article]

Objectives: To describe in detail the techniques for transvesical robot‐assisted radical prostatectomy (RARP) using the da Vinci Si/Xi system (Intuitive Surgical, Sunnyvale, CA, USA) and to evaluate functional and oncological outcomes in 35 patients with prostate cancer. Patients and Methods: Thirty‐five patients with localized prostate cancer were enrolled for transvesical RARP. The patients' preoperative data (mean ± sd age 63.4 ± 8.1 years, body mass index 28.6 ± 5.3 kg/m2, total prostate‐specific antigen 10.8 ± 4.9 ng/mL and prostate volume 30.6 ± 14.4 mL, and median [interquartile range {IQR}] biopsy Gleason score 6 [6–7], and International Index of Erectile Function [IIEF]‐5 score 18 [16–20]) were collected. Preoperative assessment revealed 28 cases of cT2a and seven cases of cT2b disease. All patients were continent preoperatively (defined as no pad required or one dry pad per day as a precaution). Surgical results and peri‐operative complications were assessed. All patients were followed up for at least 12 months postoperatively. Results: The mean operating time was 150 ± 35 min. Estimated blood loss was 100 ± 45 mL. Urinary infection was noted in one patient and managed with levofloxacin. Another patient complained of nocturia on postoperative day 14, which was relieved with solifenacin succinate. Urethral catheters were removed on postoperative day 7. Thirty‐two patients achieved immediate urinary continence, with three patients returning to full continence on postoperative day 14. Postoperative pathology confirmed 24 pT2a cases, nine pT2b cases and two pT2c cases (median [IQR] Gleason score 6 [6–7]). Positive surgical margins were found in four patients (11.4%). No urethral stricture or urinary leakage was noted on urethrocystography taken 3 months after surgery. Urodynamic studies were performed preoperatively and 6 months after surgery: median (IQR) maximum urinary flow 12.2 (10.2–14.9) vs 13.7 (10.1–15.0) mL/s; bladder capacity 385.3 (351.3–410.2) vs 370.2 (330.1–395.4) mL; and voiding phase detrusor contractility 38.5 (27.8–42.3) vs 35.6 (28.3–41.3) mmH2O, respectively. During a minimum of 12 months of follow‐up, no biochemical recurrence was noted in any patient. The median (IQR) IIEF‐5 score was 17 (16–19). Conclusions: The transvesical approach is a valid alternative to RARP in selected patients, providing promising postoperative urinary continence. Long‐term functional and oncological results require further investigation. [ABSTRACT FROM AUTHOR]

Objective: To summarize the clinical experiences with single‐port (SP) robot‐assisted radical prostatectomy (RARP) reported in the literature and to describe the peri‐operative and short‐term outcomes of this procedure. Material and Methods: A systematic review of the literature was performed in December 2019 using Medline (via PubMed), Embase (via Ovid), Cochrane databases, Scopus and Web of Science (PROSPERO registry number 164129). All studies that reported intra‐ and peri‐operative data on SP‐RARP were included. Cadaveric series and perineal or partial prostatectomy series were excluded. Results: The pooled mean operating time, estimated blood loss, length of hospital stay and catheterization time were 190.55 min, 198.4 mL, 1.86 days and 8.21 days, respectively. The pooled mean number of lymph nodes removed was 8.33, and the pooled rate of positive surgical margins was 33%. The pooled minor complication rate was 15%. Only one urinary leakage and one major complication (transient ischaemic attack) were recorded. Regarding functional outcomes, pooled continence and potency rates at 12 weeks were 55% and 42%, respectively. Conclusions: The present analysis confirms that SP‐RARP is safe and feasible. This novel robotic platform resulted in similar intra‐operative and peri‐operative outcomes to those obtained with the standard multiport da Vinci system. The advantages of single incision can be translated into a preservation of the patient's body image and self‐esteem and cosmesis, which have a great impact on a patient's quality of life. [ABSTRACT FROM AUTHOR]

Objectives: To examine the anatomical distribution of prostate cancer (PCa) recurrence on gallium‐68 prostate‐specific membrane antigen (68Ga‐PSMA) positron‐emission tomography (PET)/computed tomography (CT) in patients with biochemical recurrence (BCR) after undergoing radical prostatectomy (RP) with pathological lymph node metastasis (pN1) in their extended pelvic lymph node dissection (ePLND), and to compare the location of PCa recurrence with the location of the initial lymph node metastasis at ePLND. Materials and Methods: We retrospectively reviewed 100 patients with BCR (PSA 0.05–5.00 ng/mL) after RP with pN1 ePLND who underwent 68Ga‐PSMA PET/CT to guide salvage therapy. Clinical and pathological features and anatomical locations of PCa recurrence on 68Ga‐PSMA PET/CT were obtained, and management impact was recorded. Results: In all, 68 patients (68%) had a positive and 32 patients (32%) had a negative 68Ga‐PSMA PET/CT result. Of the 68 patients with a positive 68Ga‐PSMA PET/CT, 44 (65%) showed abnormal uptake only in the pelvic area, seven (10%) only outside the pelvic area, and 17 (25%) both within and outside the pelvic area. 68Ga‐PSMA PET/CT‐positive pelvic lymph nodes were often (84%) detected on the same side as the lymph node metastasis diagnosed at ePLND. Based on the outcomes of the 68Ga‐PSMA PET/CT, change of management was noted in 68% of the patients. Conclusion: Recurrence of PCa on 68Ga‐PSMA PET/CT was limited to the pelvis in the majority of patients with BCR after RP with pN1 ePLND. Moreover, recurrence was often detected on the same side as the lymph node metastasis at ePLND. The results confirm the diagnostic value of 68Ga‐PSMA PET/CT in patients with BCR after RP with pN1 ePLND. Prospective studies are needed to support the long‐term benefit of 68Ga‐PSMA PET/CT‐dictated management changes. [ABSTRACT FROM AUTHOR]

Objectives: To assess change in functional outcomes after a second focal high‐intensity focused ultrasonography (HIFU) treatment compared with outcomes after one focal HIFU treatment. Patients and Methods: In this multicentre study (2005–2016), 821 men underwent focal HIFU for localized non‐metastatic prostate cancer. The patient‐reported outcome measures of International Prostate Symptom Score (IPSS), pad usage and erectile function (EF) score were prospectively collected for up to 3 years. To be included in the study, completion of at least one follow‐up questionnaire was required. The primary outcome was comparison of change in functional outcomes between baseline and follow‐up after one focal HIFU procedure vs after a second focal HIFU procedure, using IPSS, Expanded Prostate Cancer Index Composite (EPIC) and International Index of Erectile Function (IIEF) questionnaires. Results: Of 821 men, 654 underwent one focal HIFU procedure and 167 underwent a second focal HIFU procedure. A total of 355 (54.3%) men undergoing one focal HIFU procedure and 65 (38.9%) with a second focal HIFU procedure returned follow‐up questionnaires, respectively. The mean age and prostate‐specific antigen level were 66.4 and 65.6 years, and 7.9 and 8.4 ng/mL, respectively. After one focal HIFU treatment, the mean change in IPSS was −0.03 (P = 0.02) and in IIEF (EF score) it was −0.4 (P = 0.02) at 1–2 years, with no subsequent decline. Absolute rates of erectile dysfunction increased from 9.9% to 20.8% (P = 0.08), leak‐free continence decreased from 77.9% to 72.8% (P = 0.06) and pad‐free continence from 98.6% to 94.8% (P = 0.07) at 1–2 years, respectively. IPSS prior to second focal HIFU treatment compared to baseline IPSS prior to first focal HIFU treatment was lower by −1.3 (P = 0.02), but mean IPSS change was +1.4 at 1–2 years (P = 0.03) and +1.2 at 2–3 years (P = 0.003) after the second focal HIFU treatment. The mean change in EF score after the second focal HIFU treatment was −0.2 at 1–2 years (P = 0.60) and −0.5 at 2–3 years (P = 0.10), with 17.8% and 6.2% of men with new erectile dysfunction. The rate of new pad use was 1.8% at 1–2 years and 2.6% at 2–3 years. Conclusion: A second focal HIFU procedure causes minor detrimental effects on urinary function and EF. These data can be used to counsel patients with non‐metastatic prostate cancer prior to considering HIFU therapy. [ABSTRACT FROM AUTHOR]

A review of the article "The NeuroSAFE approach to nerve sparing in robotic assisted radical prostatectomy in a British setting a prospective observational comparative study" G. Mirmilstein is presented.

The article offers the authors' insights on the article "5-year oncologic outcomes of Endoscopic Extraperitoneal Radical Prostatectomy (EERPE) for prostate cancer: results from a medium-volume United Kingdom centre," by A. S. McNeill and colleagues. Topics discussed by the authors include the data presentation of the paper, the impact of the steep learning curve, and the positive surgical margin (PSM) rate.

Further clinical studies are necessary to better define specific patient characteristics that can predict better clinical outcomes, the optimal duration of therapy, and factors to improve patient compliance in PTT. Abbreviations ED erectile dysfunction PD Peyronie's disease PTT penile traction therapy RxPTT RestoreX PTT Penile traction therapy (PTT) has emerged as an attractive conservative treatment for Peyronie's disease (PD) and published international guidelines recommended Grade B, Level 2 Evidence regarding the use of PTT as an effective and safe treatment [[1]]. Furthermore, numerous clinical studies have shown that PTT can be an effective and safe monotherapy or as an adjunct therapy with concurrent oral or intralesional therapy, in both acute and chronic phases of PD [[8], [10]]. [Extracted from the article]