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Context: Bladder cancer (BCa) is the fourth most common cancer in men. Survival from the disease has not improved in the last 25 yr. Population-based screening theoretically provides the best opportunity to improve the outcomes of aggressive BCa., Objective: To review the current literature regarding the usefulness and feasibility of screening for bladder cancer., Evidence Acquisition: We conducted a nonsystematic review restricted to English using the keywords urinary bladder neoplasms, mass screening, mandatory testing, and early detection of cancer. We retrieved 184 articles and selected 22., Evidence Synthesis: There was no level 1 evidence (obtained from a randomised controlled trial [RCT]) addressing the impact of screening on BCa survival or tumour downstaging. No study assessed the diagnostic performance of urinary markers in the context of screening. Two case-control series suggested a benefit of screening on survival, and a third found a nonsignificant beneficial trend in favour of screening. Two studies suggested downstaging of BCa at diagnosis. Other reports concluded that most cancers detected with screening were of low grade and that current urinary testing cannot detect all tumours. Screening is likely to be of benefit in high-risk populations using cost-efficient high-performing urinary biomarkers. There was insufficient evidence to define an efficient screening protocol., Conclusions: Although BCa screening is theoretically feasible in a high-risk population, there is currently insufficient evidence to recommend it. This is due to insufficient data to define an efficient screening protocol with selection of an appropriate population and the lack of accurate and cost-effective urinary markers able to discriminate low-risk from high-risk cancers. Major improvements are needed in the evaluation of urinary biomarkers before evaluation in a RCT can be achieved., (Copyright © 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: Pathology standards for the diagnosis of bladder cancer (BCa) have recently evolved to better reflect patient diagnosis and clinical outcomes., Objective: To update pathology reporting standards for BCa., Evidence Acquisition: We searched the international medical literature and reviewed all articles that addressed BCa gross dissection, pathologic diagnosis, staging, and reporting as of June 6, 2012. We also reviewed the proceedings from the recent Second International Consultation on Bladder Cancer (Vienna, Austria). The literature selected for review focuses on evidence-based studies that address histopathologic factors in BCa, with emphasis placed on factors that influence patient diagnosis and clinical outcomes., Evidence Synthesis: We separated data into three main components for analysis based on the type of specimen obtained: (1) transurethral resection specimens, with an emphasis on pathologic staging, variants of urothelial carcinoma, angiolymphatic invasion, and relevant ancillary techniques such as immunohistochemistry in assessing these features; (2) cystectomy specimens, with an emphasis on pT0 disease, prostatic involvement by urothelial carcinoma and lymph node dissection and analysis; and (3) cytology correlates, with recommendations for the use of cytology paired with tissue-based sampling. Areas of controversy are described and recommendations based on existing guidelines are provided. The value of a multidisciplinary team is highlighted., Conclusions: Ongoing international collaborations amongst pathologists have led to emerging standards in the reporting and microscopic diagnosis of BCa specimens. Although some areas remain controversial, we present the most up-to-date data and guidelines relevant to neoplastic pathology of the urinary bladder., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: The Second International Consultation on Bladder Cancer recommendations on urothelial carcinoma (UC) of the prostate were presented at the 2011 European Association of Urology Congress in Vienna, Austria, on March 18, 2011., Objective: Our aim is to summarize the Second International Consultation on Bladder Cancer recommendations on UC of the prostate to help clinicians assess the current evidence-based management., Evidence Acquisition: The committee performed a thorough review of new data and updated previous recommendations. Levels of evidence and grades of recommendation were assigned based on a systematic review of the literature that included a search of online databases and review articles., Evidence Synthesis: Once a non-muscle-invasive high-grade tumor or carcinoma in situ (CIS) of the bladder has been diagnosed, careful follow-up of the prostatic urethra is necessary. Noninvasive UC including CIS of the prostate should be treated with intravesical bacillus Calmette-Guérin (BCG) following endoscopic resection. A transurethral resection of the prostate may improve contact of BCG with the prostatic urethra, and it appears that response rates to BCG are increased (level of evidence: 3). Transurethral biopsy of the prostatic urethra is effective in identifying prostatic involvement but may not accurately reveal the extent of involvement, particularly with stromal invasion. Stromal invasion by UC of the prostate carries a poor prognosis. Radical cystoprostatectomy is the treatment of choice for locoregional control in patients with prostatic stromal invasion., Conclusions: These recommendations contain updated information on the diagnosis and treatment of UC of the prostate. However, prospective trials are needed to further elucidate the best management of these patients., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: New guidelines of the International Consultation on Urological Diseases for the treatment of muscle-invasive bladder cancer (MIBC) have recently been published., Objective: To provide a comprehensive overview of the current role of radical cystectomy (RC) in MIBC., Evidence Acquisition: A detailed Medline analysis was performed for original articles addressing the role of RC with regard to indication, timing, surgical extent, perioperative morbidity, oncologic outcome, and follow-up. The analysis also included radiation-based bladder-preserving strategies., Evidence Synthesis: The major findings are presented in an evidence-based fashion and are based on large retrospective unicenter and multicenter series with some prospective data., Conclusions: Open RC is the standard treatment for locoregional control of MIBC. Delay of RC is associated with reduced cancer-specific survival. In males, standard RC includes the removal of the bladder, prostate, seminal vesicles, and distal ureters; in females, RC includes an anterior pelvic exenteration including the bladder, entire urethra and adjacent vagina, uterus, and distal ureters. A procedure sparing the urethra and the urethra-supplying autonomous nerves can be performed in case of a planned orthotopic neobladder. Further technical variations (ie, seminal-sparing or vaginal-sparing techniques) aimed at improving functional outcomes must be weighed against the risk of a positive margin. Laparoscopic surgery is promising, but long-term data are required prior to accepting it as an option equivalent to the open procedure. Lymphadenectomy should remove all lymphatic tissue around the common iliac, external iliac, internal iliac, and obturator region bilaterally. Complications after RC should be reported according to the modified Clavien grading system. In selected patients with MIBC, bladder-preserving therapy with cystectomy reserved for tumor recurrence represents a safe and effective alternative to immediate RC., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: We present a summary of the Second International Consultation on Bladder Cancer recommendations on chemotherapy for the treatment of bladder cancer using an evidence-based strategy., Objective: To review the data regarding chemotherapy in patients with clinically localized and metastatic bladder cancer with a focus on its use for patients in the neoadjuvant and adjuvant settings., Evidence Acquisition: Medline databases were searched for original articles published prior to April 1, 2012, using the following search terms: bladder cancer, urothelial cancer, metastatic, advanced, neoadjuvant, and adjuvant therapy. Proceedings of major conferences from the last 5 yr also were searched. Novel and promising drugs currently in clinical trials were included., Evidence Synthesis: The major findings are addressed in an evidence-based manner. Prospective trials and important cohort data were analyzed., Conclusions: Cisplatin-based combination chemotherapy for advanced and metastatic bladder cancer is an established standard, improving overall survival. In the advanced setting, cisplatin-ineligible patients may benefit from gemcitabine and carboplatin. Meta-analyses undertaken for neoadjuvant cisplatin-based combination chemotherapy show a 5% benefit in overall survival. Pathologic complete remission may be an intermediate surrogate for survival, but requires further validation. Use of neoadjuvant chemotherapy is low, and is attributable to patient and physician choice because of limited benefit, advanced age, and comorbidities including renal and/or cardiac dysfunction. Sufficient data to support adjuvant chemotherapy are lacking., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: Prostate cancer (PCa) remains an increasingly common malignancy worldwide. The optimal management of clinically localized, early-stage disease remains unknown, and profound quality of life issues surround PCa interventions., Objective: To systematically summarize the current literature on the management of low-risk PCa with active surveillance (AS), with a focus on patient selection, outcomes, and future research needs., Evidence Acquisition: A comprehensive search of the PubMed and Embase databases from 1980 to 2011 was performed to identify studies pertaining to AS for PCa. The search terms used included prostate cancer and active surveillance or conservative management or watchful waiting or expectant management. Selected studies for outcomes analysis had to provide a comprehensive description of entry characteristics, criteria for surveillance, and indicators for further intervention., Evidence Synthesis: Data from seven large AS series were reviewed. Inclusion criteria for surveillance vary among studies, and eligibility therefore varies considerably (4-82%). PCa-specific mortality remains low (0-1%), with the longest published median follow-up being 6.8 yr. Up to one-third of patients receive secondary therapy after a median of about 2.5 yr of surveillance. Surveillance protocols and triggers for intervention vary among institutions. Most patients are treated for histologic reclassification (27-100%) or prostate-specific antigen doubling time <3 yr (13-48%), while 7-13% are treated with no evidence of progression. Repeat prostate biopsy with a minimum of 12 cores appears to be important for monitoring patients for changes in tumor histology over time., Conclusions: AS for PCa offers an opportunity to limit intervention to patients who will likely benefit the most from radical treatment. This approach confers a low risk of disease-specific mortality in the short to intermediate term. An early, confirmatory biopsy is essential for limiting the risk of underestimating tumor grade and amount., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Although the rationale for active surveillance (AS) in patients with low-risk prostate cancer is well established, eligibility criteria vary significantly across different programs., Objective: To compare the ability of contemporary AS criteria to identify patients with certain pathologic tumor features based on the results of an extended transrectal prostate biopsy., Design, Settings, and Participants: The study cohort included 391 radical prostatectomy patients who had prostate cancer with Gleason scores ≤ 6 on transrectal biopsy with ≥ 10 cores., Intervention: Radical prostatectomy without neoadjuvant treatment., Outcome Measurements and Statistical Analysis: We identified patients who fulfilled the inclusion criteria of five AS protocols including those of Epstein, Memorial Sloan-Kettering Cancer Center, Prostate Cancer Research International: Active Surveillance (PRIAS), University of California, San Francisco, and University of Miami (UM). We evaluated the ability of these criteria to predict three pathologic end points: insignificant disease defined using a classical and updated formulation, and organ-confined Gleason ≤ 6 prostate cancer. Measures of diagnostic accuracy and areas under the receiver operating curve were calculated for each protocol and compared., Results and Limitations: A total of 75% of the patients met the inclusion criteria of at least one protocol; 23% were eligible for AS by all studied criteria. The PRIAS and UM criteria had the best balance between sensitivity and specificity for both definitions of insignificant prostate cancer and a higher discriminative ability for the end points than any criteria including patients with two or more positive cores. The Epstein criteria demonstrated high specificity but low sensitivity for all pathologic end points, and therefore the discriminative ability was not superior to those of other protocols., Conclusions: Significant variations exist in the ability of contemporary AS criteria to predict pathologically insignificant prostate cancer at radical prostatectomy. These differences should be taken into account when making treatment choices in patients with low-risk prostate cancer., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon given the operative difficulty, potential for massive hemorrhage, and possibility of tumor thromboemboli., Objective: To determine the applicability of a self-developed technique based on orthotopic liver transplantation procedures for safe resection of these tumors., Design, Setting, and Participants: From August 1997 to February 2008, 68 consecutive patients underwent resection of RCC with suprahepatic and/or retrohepatic (level 3 and 4) tumor thrombus in a single referral institution., Surgical Procedure: A triradiate incision over the upper abdomen permits the placement of a Rochard retractor. Early vascular control of the renal artery is achieved by creating a posterior plane of dissection. Venous collateral decompression permits development of a bloodless anterior plane by mobilizing the liver in a "piggy-back" fashion and the spleen-pancreas en bloc to the midline. Thrombus extraction requires circumferential control at the renal veins, hepatic hilum, and IVC before cavotomy. The central tendon of the diaphragm may be opened for cranial control and gentle traction over the right atrium performed. Repositioning of the proximal clamp and Pringle release avoid veno-venous bypass and cardiopulmonary bypass (CPB) in most cases., Measurements: The extent of the tumor thrombus was retrohepatic in 56 patients and suprahepatic/intra-atrial in 12 patients., Results and Limitations: Mean operative time was 5 h 32 min. Mean estimated blood loss (EBL) was 2112±3834 ml (range: 100-25 000), with a mean transfusion being 4.2±4.1 U (range: 0-30). Five patients (7.3%) required CPB. Three patients (4.4%) died in the immediate postoperative period. All had complete tumor resection. No patient developed intraoperative thromboembolism., Conclusions: This surgical approach provides excellent exposure and control of the IVC in cases with level 3 and 4 tumor thrombus, avoiding CPB except in rare circumstances., (Copyright © 2010 European Association of Urology. All rights reserved.)

Background: With the advent of prostate-specific antigen (PSA) screening and the increase in the number of transrectal ultrasound-guided biopsy cores, there has been a dramatic rise in the incidence of low-risk prostate cancer (LRPC). Because > 97% of men with LRPC are likely to die of something other than prostate cancer, it is critical that patients give thought to whether early curative treatment is the only option at diagnosis., Objective: To identify a group of men with LRPC who may not require initial treatment and monitor them on our active surveillance (AS) protocol, to determine the percentage treated and the outcome and to analyze the quality-of-life data., Design, Setting, and Participants: We defined patients eligible for AS as Gleason ≤ 6, PSA ≤ 10, and two or fewer biopsy cores with ≤ 20% tumor in each core., Measurements: Kaplan Meier analysis was used to predict the 5-year treatment free survival. Logistic regression determined the predictors of treatment. Data on sexual function, continence, and outcome were obtained and analyzed., Results and Limitations: The AS cohort consisted of 230 patients with a mean age of 63.4 yr; 86% remained on AS for a mean follow-up of 44 mo. Thirty-two of the 230 patients (14%) were treated for a mean follow-up of 33 mo. Twelve had a total prostatectomy (TP). The pathologic stage of these patients was similar to initially treated TP patients with LRPC. Fourteen underwent radiation therapy, and six underwent androgen-deprivation therapy. Fifty percent of patients had no tumor on the first rebiopsy, and only 5% of these patients were subsequently treated. PSA doubling time and clinical stage were not predictors of treatment. No patient progressed after treatment. Among the AS patients, 30% had incontinence, yet < 15% were bothered by it. As measured by the Sexual Health Inventory for Men, 49% of patients had, at a minimum, moderate (≤ 16) erectile dysfunction., Conclusions: If guidelines for AS are narrowly defined to include only patients with Gleason 6, tumor volume ≤ 20% in one or two biopsy cores, and PSA levels ≤ 10, few patients are likely to require treatment. Progression-free survival of those treated is likely to be equivalent to patients with similar clinical findings treated at diagnosis., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Renal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management., Objective: To evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy., Design, Setting, and Participants: We performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed., Measurements: Disease-free survival (DFS) and disease-specific survival (DSS) were studied., Results and Limitations: The median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups-supradiaphragmatic and infradiaphragmatic-there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non-clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non-clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis., Conclusions: Radical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non-clear-clear cell histology are significant prognostic factors influencing DSS., (Copyright © 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: For bladder cancer (BCa) patients undergoing bladder-sparing treatments, molecular markers may aid in accurately predicting progression to muscle invasion and recurrence. Hyaluronic acid (HA) is a glycosaminoglycan that promotes tumor metastasis. Hyaluronoglucosaminidase 1 (HYAL-1)-type hyaluronidase (HAase) promotes tumor growth, invasion, and angiogenesis. Urinary HA and HAase levels are diagnostic markers for BCa., Objective: We evaluated whether HA and HYAL-1 can predict progression to muscle invasion and recurrence among patients with non-muscle-invasive BCa., Design, Setting, and Participants: : Based on tissue availability, tissue microarrays were prepared from a cohort of 178 BCa specimens (144 non-muscle invasive, 34 muscle invasive). Follow-up information was available on 111 patients with non-muscle-invasive BCa (mean follow-up: 69.5 mo); 58 patients recurred and 25 progressed to muscle invasion (mean time to progress: 22.3 mo)., Measurements: HA and HYAL-1 expression was evaluated by immunohistochemistry and graded for intensity and area of staining. Association of HA and HYAL-1 staining with BCa recurrence and muscle invasion was evaluated by univariate and multivariate models., Results and Limitations: HA and HYAL-1 expression correlated with tumor grade, stage, and multifocality (p<0.05). In non-muscle-invasive BCa specimens, HYAL-1 staining was higher (234.3+/-52.2; 200.6+/-61.4) if patients experienced progression to muscle invasion or recurrence when compared with no progression or recurrence (164.1+/-48.2; 172.1+/-57; p<0.001). HA staining correlated with muscle invasion (p<0.001). In univariate analysis, age (p=0.014), multifocality (p=0.023), and HYAL-1 staining (p<0.001) correlated with muscle invasion, whereas only HYAL-1 correlated with recurrence (p=0.013). In multivariate analysis, HYAL-1 significantly associated with muscle invasion (p<0.001; 76.8% accuracy) and recurrence (p=0.01; 67.8% accuracy)., Conclusions: HYAL-1 is a potential prognostic marker for predicting progression to muscle invasion and recurrence.

Objectives: As the number of prostate cancer survivors is increasing, the long-term health of prostate cancer patients has become a significant health issue. Radiation is known to induce malignant transformation, and prostate cancer radiotherapy is suggested to induce secondary malignancies. This report reviews the available data regarding the risk of secondary cancer after radiation for prostate cancer., Methods: Epidemiological studies of the secondary cancer risk in patients with a history of prostate cancer radiation and the literature regarding radiation-induced carcinogenesis were reviewed., Results: Prostate cancer is not associated with an increased number of additional malignancies. The data suggests a modest increase in secondary cancers associated with radiation for prostate cancer, as approximately one in 70 patients undergoing radiation and surviving more than 10 yr will develop secondary cancer. The most common sites for secondary cancers are bladder and rectum. In addition to the cancers adjacent to the radiation field, there is also an increase of cancers in distant sites, such as lung. The increased risk for secondary cancers is reported after external radiation, not after brachytherapy. The available data originated from studies of patients undergoing conventional radiotherapy. New treatment methods, such as intensity-modulated radiotherapy, may be associated with a higher risk of secondary cancers., Conclusion: Although the incidence of secondary cancers after prostate cancer radiotherapy is not dramatically different from the overall population, patients should be informed about this risk. Other treatment modalities should be considered for patients with long life expectancy and for patients with additional risk factors.

Objectives: The routine placement of a pelvic drain following radical retropubic prostatectomy (RRP) may not be required. We describe our experience in 552 consecutive RRPs to emphasise the safety of this approach and explain our rationale for avoiding a drain when possible., Methods: RRP was performed in 552 consecutive patients with clinically localised adenocarcinoma of the prostate between January 2002 and June 2005. Clinical and pathologic information was documented for each patient. After the prostate was removed and the anastomotic sutures tied, the bladder was gently filled with approximately 50 ml of saline through the urethral catheter. If there was no leak, a drain was not placed., Results: A drain was not placed in 419 (76%) of the 552 patients. We compared the postoperative complication rates in those with (D+) and without (D-) a drain. There were 27 (5%) immediate postoperative complications and no significant difference between the two groups (D+, 6%; D-, 5%; p=0.629): three (1%) patients who did not have a drain had a urinoma, one (1%) who had a drain had a lymphocele, and two (2%) who had a drain had a small pelvic haematoma., Conclusions: If the bladder neck is preserved or meticulously reconstructed, there may be little extravasation and, thus, routine drainage is unnecessary. Our 4-year experience indicates that morbidity is not increased by omitting a drain from the pelvic cavity after RRP in properly selected cases.

Our understanding of the screening, prevention and treatment of early prostate cancer is improving. This is a result of new data from clinical trials and the incorporation of efficacy measures based on risk assessment and quality of life (QoL). This review aims to examine completed and ongoing clinical trials that address issues in early prostate cancer, including screening, prevention, treatment, and QoL. Prostate-specific antigen (PSA) testing has a crucial and evolving role in detecting primary prostate cancer, evaluating prevention interventions and assessing the effectiveness of treatment. Questions remain about the optimal PSA parameters appropriate for primary screening and for diagnosing relapse. Emerging and established data provide evidence that early intervention with hormone therapy, either as immediate or adjuvant therapy, delays progression in prostate cancer patients with intermediate or poor prognosis. The impact of therapeutic modality on QoL has become better characterized, as QoL instruments have been developed, validated and applied.

Introduction: Transrectal ultrasound (TRUS)-guided biopsy is a very common office procedure for most urologists. Pain or discomfort associated with this procedure has been addressed recently by the use of periprostatic local anesthesia. We re-address this issue with an update of our experience and emphasize the crucial steps that contribute to the success of the technique. We also analyzed the subsequent intraoperative effects of injecting lidocaine into the area of the neurovascular bundles., Materials and Methods: Between June 1999 and December 2000, 200 patients underwent TRUS-guided biopsies of the prostate. Patients were properly consented and subjected to the procedure using periprostatic nerve block with 10 cm3 of 1% plain lidocaine. An 'ultrasonographic wheal' was created between the rectal wall and the posterior aspect of the prostate and three or four different locations along the neurovascular bundles. Pain scores were evaluated with the visual analogue scale., Results: TRUS biopsy of the prostate was performed in 200 consecutive patients using periprostatic local anesthesia, 40 patients (20%) had undergone previous prostate biopsy without anesthesia. The age of patients ranged from 44 to 75 years (mean 67). The number of biopsies ranged from 6 to 14. Mean time from introduction of the probe per rectum to the end of the procedure was 18 min. There were no instances of clinical infection, significant bleeding, urinary retention, diaphoresis or hypotension. The visual analogue scale ranged from 1 to 3 (mean 2). Intraoperative findings in 62 patients who subsequently underwent nerve-sparing radical retropubic prostatectomy were no different from the patients who had biopsies without a local anesthetic., Conclusion: TRUS-guided biopsy of the prostate is the procedure of choice for diagnosing prostate cancer. This procedure can be accomplished with minimal pain with the use of periprostatic local anesthesia. It is an easy, safe, acceptable and reproducible technique that we believe should be considered for all patients undergoing TRUS biopsy regardless of age or number of biopsies.

In patients with localised prostate cancer and a life expectancy of at least 10 years, radical prostatectomy is increasingly being performed. Pre-operative clinical staging of prostate cancer is, however, inaccurate with around 10-20% of clinical T1, 10-30% of clinical T2a, and 30-60% of clinical T2b cases having tumour at the surgical margin. There is no documented best treatment for patients with a positive surgical margin. Options include close observation, adjuvant radiation therapy or androgen deprivation. The role of induction androgen deprivation has, therefore, evolved in an attempt to improve upon the cure rate for radical prostatectomy, and in this review results from clinical trials are discussed. In the largest United States randomised trial in patients with stage T2b prostate cancer, pre-operative androgen deprivation resulted in a significantly lower rate of positive surgical margins, normalisation of prostate-specific antigen and a decrease in the size of the prostate. Sufficient follow-up is required from all of the completed prospective randomised trials before pre-operative androgen deprivation can be justified in all T2b patients.

Between January 1992 and September 1993, 813 patients with stage D2 prostate cancer were enrolled in a multicentre, double-blind (for antiandrogen therapy) trial and randomised to antiandrogen therapy with Casodex (bicalutamide, 50 mg once daily) or flutamide (250 mg three times daily) and to luteinising hormone-releasing hormone (LHRH) analogue therapy with Zoladex (goserelin, 3.6 mg every 28 days) or leuprolide (7.5 mg every 28 days). Time to treatment failure was the primary efficacy endpoint. At a median follow-up time of 49 weeks, there was a significant (p = 0.005) difference between groups in time to treatment failure in favour of Casodex plus LHRH analogue. Overall, 168 (42%) of 404 patients in the Casodex plus LHRH analogue group and 218 (53%) of 409 patients in the flutamide plus LHRH analogue group reached a treatment failure endpoint. Although a cause-specific treatment-failure analysis was not performed, the difference between groups in treatment failure attributed to adverse events (mainly diarrhoea) was evident primarily in the first 7 months of therapy. The difference between groups in treatment failure for objective progression was most evident after 1 year of therapy. With further follow-up (median time of 95 weeks), the result for time to treatment failure, although no longer statistically significant, were consistent with the previous finding of an improvement in time to treatment failure associated with Casodex plus LHRH analogue therapy. With a median of 95 weeks of follow-up, 34% of deaths had occurred. The survival analysis was not dissimilar between the 2 groups. At 49 weeks median follow up, the incidence of diarrhoea was significantly (p < 0.001) lower among patients in the Casodex plus LHRH analogue group. Diarrhoea led to withdrawal from therapy for 2 patients in the Casodex plus LHRH analogue group, compared with 25 patients in the flutamide plus LHRH analogue group. In conclusion, Casodex plus LHRH analogue is well tolerated and effective with an improvement in time to treatment failure over flutamide plus LHRH analogue. Survival was not dissimilar between the 2 treatment groups.

We present a case of bilateral testicular epidermoid cysts. These lesions were identified in a 22-year-old male who had previously experienced mild testicular trauma. Management consisted of inguinal exploration and wedge resection on one side and transscrotal exploration and excision on the other. This case represents the second reported case of bilateral conservative management of testicular epidermoid cysts in an adult male. The etiology and management alternatives for testicular epidermoid cysts are discussed.

Between December 1991 and January 1994, 134 patients underwent radical retropubic prostatectomy with bladder neck preservation. Forty-nine patients had a positive margin. Number and location of positive margins were analyzed. A tumor was identified at the bladder neck in 10 cases (7.5%). In all 10 patients with bladder neck involvement, a tumor was also identified at multiple other sites. These data suggest that preservation of the bladder neck during radical prostatectomy does not appear to compromise the efficacy of the procedure. Using a self-administered patient questionnaire, we evaluated the effect of bladder neck preservation upon continence in 36 patients. At the initial 3-month follow-up, 24 (67%) patients did not wear any pads. Another 7 (19%) wore pads occasionally, while 5 (14%) patients wore pads daily. To date only 1 of the 134 patients has developed an anastomotic stricture. Bladder neck preservation may aid in an earlier return of continence following radical prostatectomy and reduces anastomotic strictures. It does not appear to compromise the removal of the cancer.

Terazosin, a selective, long-acting alpha 1-adrenergic blocker, was evaluated in 44 men with benign prostatic hyperplasia. The dose was titrated from 2 to 20 mg nightly depending on improvement in symptoms and flow rate. All men completed at least 3 months of therapy, 26 had 6 months and 19 received 9-12 months of terazosin. There was an average increase of 2 ml/s in the peak urinary flow rate compared to baseline. This was statistically significant at the 3-month level. Residual urine decreased under treatment at each 3-month time interval. Prior to initiation of terazosin the mean was 165 ml, and it was 62, 100, and 41 ml at 3, 6 and 9 months respectively. There was a statistically significant improvement in both the obstructive and irritative symptom scores. Side effects were minimal; only 1 patient discontinued terazosin due to a hypotensive episode. Terazosin was found to be safe and effective in the dose range of 2-20 mg taken at bedtime in men with symptoms related to benign prostatic hyperplasia. The present study did not identify any baseline parameters such as initial prostate volume, peak flow rates, or obstructive or irritative symptom scores that correlated with clinical outcome.