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Purpose Various techniques for EEP exist. They differ by surgical steps and the source of energy. It is assumed that the latter is of minor importance, whereas adherence to the anatomical enucleation template determines the postoperative result. So far, no systematic review highlights the differences between the energy sources in use for anatomical EEP. This study will address selfsame topic. Methods A systematic review of the literature was completed on September 1st, 2020. Studies comparing HoLEP, ThuLEP, DiLEP, or BipolEP with TUR-P providing 12 months of postoperative follow-up were included. Two frequentist network meta-analyses were created to compare the techniques of EEP indirectly. Results 31 studies, including 4466 patients, were found eligible for our meta-analysis. Indirect pairwise comparison showed differences in surgery time between BipolEP and HolEP (MD − 16.72 min., 95% CI − 27.75 to − 5.69) and DiLEP and HoLEP (MD − 22.41 min., 95% CI − 39.43 to − 5.39). No differences in the amount of resected prostatic tissue, major and minor complications and postoperative catheterization time were found. The odds for blood transfusions were threefold higher for BipolEP than for HoLEP (OR 3.27, 95% CI 1.02–10.5). The difference was not statistically significant when comparing prospective trials and matched-pair analysis only (OR 3.25, 95% CI 0.94–11.18). The Qmax 12 months after surgery was 2 ml/sec. higher for BipolEP than for DiLEP (MD 2.00, 95% CI 0.17–3.84) and 1.94 ml/sec. lower for DiLEP than for HoLEP (MD − 1.94, 95% CI − 3.65 to − 0.22). Conclusion The energy source used for EEP has an impact on the intervention itself. BipolEP promotes surgical efficiency; laser techniques lower the risk of bleeding. Registry This meta-analysis is registered in the PROSPERO international prospective register registry with the registration number CRD42020205836.

Purpose The value of bladder cancer (BC) substaging into macroscopic (pT3b) and microscopic (pT3a) perivesical fat extension in lymph node (Ln)-negative patients is controversially discussed and limited evidence for prognostic relevance of additional histopathological factors in pT3 BC exists. We evaluated the prognostic value of pT3 substaging and established pathological and clinical parameters with focus on tumor invasive front (TIF) and tumor size. Methods Specimens of 52 patients treated with radical cystectomy (RC) for pT3 a/b muscle-invasive BC were reviewed and re-evaluated by a pathologist specialized in uropathology. Clinical variables and standard histopathologic characteristics were assessed including TIF and tumor size. Their value as prognosticators for overall survival (OS) and recurrence-free survival (RFS) was evaluated. Results Mean age of patients was 67.55 years. Tumors were staged pT3a in 28 patients (53.8%) and pT3b in 24 (46.8%). Median OS was 34.51 months. Median tumor size was 3.2 cm, median TIF was 11.0 mm. Differences in OS between pT3a and pT3b were not significant (p = 0.45). Carcinoma in situ (CIS) and lymphovascular invasion (LVI) were significantly associated with pT3b tumors. Univariate analysis could not identify pathological prognosticators like TIF or tumor size for OS and RFS (p for all > 0.05). Conclusion No significant differences in OS or RFS were observed comparing Ln-negative pT3 BC following radical cystectomy. Additional pathologic variables like TIF could not be identified as prognosticator. Relevance of pT3 BC substaging needs reevaluation in larger prospective cohorts.

Purpose To review the existing available information regarding urolithiasis management and the impact of COVID-19 on this, and propose recommendations for management of emergency urolithiasis presentations in the COVID-19 era. Methods Review of published guidelines produced by Urological Governing Bodies, followed by the literature review regarding urolithiasis management during the COVID-19 pandemic. Results Consistent recommendations across guidelines and literature were that urolithiasis with concurrent sepsis or renal failure remains a urological emergency warranting urgent intervention within the pandemic environment. Ureteric stenting and percutaneous nephrostomy are considered equivalent for decompression in this setting, with both ideally to be performed under local anaesthesia where possible to spare ventilators and reduce aerosol-generating procedures. Greater utilization of medical expulsive therapy and dissolution chemolysis may occur during the pandemic, and longer indwelling stent times may be accepted while definite stone clearance is deferred. Conclusions Urolithiasis will continue to be a source of emergency presentations requiring urgent intervention during the COVID-19 pandemic. However, it is possible to limit these interventions to decompression of the collecting system in the setting of concurrent obstruction or infection, performed under local anaesthesia to limit use of resources and minimise aerosol-generating procedures, with deferral of definitive management. Electronic supplementary material The online version of this article (10.1007/s00345-020-03491-7) contains supplementary material, which is available to authorized users.

Purpose Radiotherapy (RT), as part of trimodal therapy, is an attractive alternative treatment in patients with urothelial muscle-invasive bladder cancer (MIBC). There is accumulating evidence suggesting the immunomodulatory effects of RT and its potential synergy when combined with immunotherapy. The aim of this review was to report on the most recent advances on this combination, including the mechanisms of RT immunomodulation, practical approach to combining RT and immunotherapy, and ongoing clinical trials in bladder cancer. Methods Using the PubMed database, we identified articles published between March 2004 and April 2020 on the combination of RT with immunotherapy in localized or metastatic MIBC. A search of the Clinicaltrials.gov and Clinicaltrialsregister.eu/ retrieved ongoing clinical trials on the topic as well. Results Combination of RT with immunotherapy leads to immunogenic cell death and an increase in immune markers thus leading to improved tumor control. For localized MIBC, there are safety concerns related to the use of concurrent immunotherapy with hypofractionated RT, thus neoadjuvant or adjuvant immunotherapy is preferred. In the metastatic setting, the combination of multi-site RT with SBRT-like doses (≥ 6 Gy per fraction) and concurrent immunotherapy seems most efficacious at harnessing the abscopal effect. At least 25 clinical trials combining immunotherapy and RT in MIBC are currently ongoing and will answer pending questions on safety, efficacy, and practical considerations on RT scheduling, fractionation, and targets volumes. Conclusion RT has the potential to synergize with immunotherapy to improve oncological outcomes in patient with localized or metastatic MIBC. Clinical trials results are eagerly awaited.

Objective To derive and validate a mathematical model to predict laser-induced temperature changes in a kidney during kidney stone treatment. Methods A simplified mathematical model to predict temperature change in the kidney for any given renal volume, irrigation flow rate, irrigation fluid temperature, and laser power was derived. We validated our model with matched in vitro experiments. Results Excellent agreement between the mathematical model predictions and laboratory data was obtained. Conclusion The model obviates the need for repeated experimental validation. The model predicts scenarios where risk of renal tissue damage is high. With real-time knowledge of flow rate, irrigating fluid temperature and laser usage, safety warning levels could be predicted. Meanwhile, clinicians should be aware of the potential risk from thermal injury and take measures to reduce the risk, such as using room temperature irrigation fluid and judicious laser use.

Purpose To describe the vacuum-assisted mini-percutaneous nephrolithotomy (vmPCNL) technique performed via the 16Ch ClearPetra sheath, to evaluate its outcomes and to analyze intrarenal pressure (IRP) fluctuations during surgery. Methods Data from all consecutive vmPCNL procedures from September 2017 to October 2019 were prospectively collected. Data included patients’ and stones characteristics, intra and peri-operative items, post-operative complications and stone clearance. Patients undergoing vmPCNL from March to October 2019 were submitted to IRP measurement during surgery. Results A total of 122 vmPCNL procedures were performed. Median stone volume was 1.92 cm3. Median operative time was 90 min and median lithotripsy and lapaxy time was 28 min. Stone clearance rate was 71.3%. Thirty-one (25.2%) patients experienced post-operative complications, seven of which were Clavien 3. Postoperative fever occurred in nine (7.4%) patients and one (0.8%) needed a transfusion. No sepsis were observed. IRPs were measured in 22 procedures. Mean IRP was 15.3 cmH2O and median accumulative time with IRP > 40.78 cmH2O (pyelovenous backflow threshold) was 28.52 sec. Maximum IRP peaks were reached during the surgical steps when aspiration is closed (mainly pyelograms), whereas during lithotripsy and suction-mediated lapaxy, the threshold of 40.78 cmH2O was overcome in three procedures. Conclusions vmPCNL is a safe procedure with satisfactory stone clearance rates. Mean IRP was always lower than the threshold of pyelo-venous backflow and the accumulative time with IRP over this limit was short in most of the procedures. During lithotripsy and vacuum-mediated lapaxy, IRP rarely raised over the threshold.

Purpose and objective We performed a systematic review on COVID-19 and its potential urological manifestations. Methods A literature search was performed using combination of keywords (MeSH terms and free text words) relating to COVID-19, urology, faeces and stool on multiple databases. Primary outcomes were the urological manifestations of COVID-19, and SARS-CoV-2 viral RNA detection in urine and stool samples. Meta-analyses were performed when there were two or more studies reporting on the same outcome. Special considerations in urological conditions that were relevant in the pandemic of COVID-19 were reported in a narrative manner. Results There were a total of 21 studies with 3714 COVID-19 patients, and urinary symptoms were absent in all of them. In patients with COVID-19, 7.58% (95% CI 3.30–13.54%) developed acute kidney injury with a mortality rate of 93.27% (95% CI 81.46–100%) amongst them. 5.74% (95% CI 2.88–9.44%) of COVID-19 patients had positive viral RNA in urine samples, but the duration of viral shedding in urine was unknown. 65.82% (95% CI 45.71–83.51%) of COVID-19 patients had positive viral RNA in stool samples, which were detected from 2 to 47 days from symptom onset. 31.6% of renal transplant recipients with COVID-19 required non-invasive ventilation, and the overall mortality rate was 15.4%. Conclusions Acute kidney injury leading to mortality is common amongst COVID-19 patients, likely as a result of direct viral toxicity. Viral RNA positivity was detected in both urine and stool samples, so precautions are needed when we perform transurethral or transrectal procedures. Electronic supplementary material The online version of this article (10.1007/s00345-020-03246-4) contains supplementary material, which is available to authorized users.

Purpose The self-reported functional status (sr-FS) of prostate cancer (PCa) patients varies substantially between patients and health-care providers before treatment. Information about this issue is important for evaluating comparisons between health-care providers and to assist in treatment decision-making. There have been few reports on correlates of pretherapeutic sr-FS. The objective of the article, therefore, is to describe clinical and sociodemographic correlates of pretherapeutic sr-FS, based on a subset of the TrueNTH Global Registry, a prospective cohort study. Methods A total of 3094 PCa patients receiving local treatment in 44 PCa centers in Germany were recruited between July 2016 and April 2018. Multilevel regression models were applied to predict five pretherapeutic sr-FS (EPIC-26) scores based on clinical characteristics (standard set suggested by the International Consortium for Health Outcomes Measurement), sociodemographic characteristics, and center characteristics. Results Impaired pretherapeutic sr-FS tended to be associated with lower educational level and poorer disease characteristics—except for “urinary incontinence” which was only associated with age. Notably, age was a risk factor (“urinary incontinence,” “urinary irritative/obstructive,” “sexual”) as well as a protective factor (“hormonal”) for pretherapeutic sr-FS. Pretherapeutic sr-FS varies little across centers. Conclusions Pretherapeutic sr-FS varies by clinical patient characteristics and age as well as by socioeconomic status. The findings point out the benefit of collecting and considering socioeconomic information in addition to clinical and demographic patient characteristics for treatment decision-making and fair comparisons between health-care providers.

Introduction As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. We aim to compare current robotic training curricula with training in aviation, to evaluate current similarities and to provide insight into how healthcare can further learn from replicating initiatives in aviation training. Methods A systematic literature review of the current evidence was conducted online and relevant publications and information were identified. Evaluation and comparison between training in robotic surgery and the aviation industry was performed. Results There are significant similarities between modern robotic training curricula and pilot training. Both undergo basic training before proceeding to advanced training. Aviation training methods include classroom instruction, e-learning and practical training, in both the aircraft and flight simulation training devices. Both surgeon and pilot training include technical and procedural instruction as well as training in non-technical skills such as crisis management, decision making, leadership and communication. However, there is more regulation in aviation, with international standards for training curricula, simulation devices and instructors/trainers that are legally binding. Continuous learning with re-qualification with benchmarked high stakes tests are also mandatory throughout a pilot’s and instructor’s career. Conclusion Robotic surgeons and pilots roles have many fundamental similarities. Both work with expensive and complex technology requiring high levels of skills, within working environments with high physiological and psychological stress levels. Whilst many initiatives in aviation training have already been replicated in surgical training there remain considerable differences in regulation. Adopting established and proven aviation methods of assessment and regulation could help robotic surgical training become more efficient, more effective and ultimately safer.

Purpose With non-technical skills (NTS) deficits being recognised as a major cause for error in surgery, there is an increasing interest in their training and evaluation. A growing number of training courses are emerging and some NTS curricula have also been created. Many different training methods are described in the literature but there is still uncertainty with regards to their optimum combination within a curriculum. Methods A literature review of the electronic database Medline was performed. All articles published before December 2018 were screened by abstract and included if deemed relevant by the author. The included articles’ reference lists were also screened for further relevant studies. Results Simulation training is accepted as the most effective way to train NTS. Within simulation training, it is shown that the ‘igloo’ full immersion/distributed simulation environment is appropriate for teaching NTS in urological scenarios where a designated operating room or space is not available. The use of multiple settings, for example wards and clinics as well as the operating room, is advantageous, as is training in an interprofessional team. Classroom teaching also plays a role in NTS training as an adjunct to simulation, with evidence that it improves some parameters of NTS. All levels, including qualified surgeons, benefit from NTS training; however, adaptation to both trainee level and specialty is important. Although less time consuming, training juniors and seniors together mainly benefits juniors, and training NTS at the same time as technical skills detracts from the quality of teaching. Debriefing is an important part of training and should be well structured; there are many debriefing models in existence, allowing for choice of method based on examiner preference and participant demographic. Furthermore, examiners should be well briefed in their task and trained in NTS assessment. Conclusion To move forward, studies should combine tried and tested learning techniques into a curriculum covering all training levels, which should then be validated and followed up long term to ensure a positive impact on patient safety.

Purpose There are sparse data describing outcomes of bone-only oligometastatic prostate cancer in comparison with lymph node disease treated with stereotactic body radiotherapy (SBRT). The primary aim of this study was to report progression-free survival (PFS) data for patients with bone-only disease. Influence of hormone sensitivity and androgen deprivation therapy use was also assessed. Methods This is a single-centre retrospective cohort study. Hormone-sensitive and castrate-resistant patients with oligometastatic (≤ 3) bone-only prostate cancer treated with SBRT were included. Data were collected using electronic records. Kaplan–Meier survivor function, log rank test, as well as Cox regression were used to calculate PFS and overall survival. Results In total, 51 patients with 64 bone metastases treated with SBRT were included. Nine patients were castrate resistant and 42 patient’s hormone sensitive at the time of SBRT. Median follow-up was 23 months. Median PFS was 24 months in hormone-sensitive patients and 3 months in castrate-resistant patients. No patients experienced grade 3 or 4 toxicities. There were three in-field recurrences. Conclusions In this study, patients with bone oligometastatic disease showed potential benefit from SBRT with a median PFS of 11 months. Hormone-sensitive patients showed the greatest benefit, with results similar to that published for oligometastatic pelvic nodal disease treated with SBRT. Prospective randomised control trials are needed to determine the survival benefit of SBRT in oligometastatic bone-only prostate cancer and to determine prognostic indicators. Electronic supplementary material The online version of this article (10.1007/s00345-019-02873-w) contains supplementary material, which is available to authorized users.

Purpose The purpose of this review is to assess the potential role of tissue engineering for urethral reconstruction. It is well- recognised that urethrotomy remains the first-line therapy in the treatment of urethral stricture. Following on from the randomised study which recommended no difference between urethrotomy and urethral dilation, Steenkamp et al. reported long-term success rates of only 20%. Patients with longer strictures, penile or distal urethral strictures, and extensive periurethral spongiofibrosis typically do not respond well to repeated incisions. This report reviews the potential role of tissue engineering as applied to augmentation urethroplasty, which is the treatment of choice following failed urethrotomy. Methods A review of the literature was carried out. The principal emphasis was on tissue engineering as applied to augmentation urethroplasty, but an introductory section reviews the use of urethrotomy and the background to contemporary practise with augmentation urethroplasty using oral mucosa. Results It is evident that a cellular matrix which requires the ingrowth of cells is unlikely to be successful except for very short strictures. Other approaches such as injection of stem cells have not been adequately trialled in humans to date. Tissue-engineered substitute for autologous oral mucosa has been used and the results relating to this are reviewed. Conclusions Tissue engineering of autologous tissue for urethroplasty is expensive. It is unnecessary for the majority of cases, but could be potentially useful for very lengthy strictures, for instance, relating to lichen sclerosis. Whilst tissue-engineered oral mucosa has been successfully used, a great deal more work would be necessary to develop an appropriate matrix. Another study has looked at a larger series using an alternative tissue-engineered substitute, but the results have been very disappointing. At present, it has to be concluded that there is no effective and validated tissue engineering solution for the management of urethral stricture disease.

Purpose The aim of this prospective study was to identify the tumour characteristics that are associated with invasiveness and those that are relevant for disease-specific survival (DSS) in upper tract urothelial carcinoma, UTUC. Methods From a prospective consecutive cohort of patients with suspicion of UTUC, those who were diagnosed with UTUC using URS prior to rNU between 2005 and 2012 were included. Tumour characteristics were analysed for prediction of invasiveness and association with DSS. Stages were categorised as superficial (pTa-1 and CIS only) or invasive (≥ pT2). Tumours were graded according to WHO 1999 classification. DSS was analysed regarding possible association with stage, grade, size, multifocality, location, ploidy and rate of proliferation. Associations were tested using Fisher’s exact test, Pearson Chi-square or Cox’s regression. Kaplan–Meier survival curves were constructed. Results Forty-five consecutive patients were included, and 43 of them were included in the final analyses because their rNU specimens were available for reassessment. The only tumour characteristics that were significantly associated with stage were tumour grade (P

The surgical mesh material used in the surgical treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women is associated with significant complications in some women. This has recently become a public health issue with involvement of national parliaments and regulatory bodies. The occurrence of mesh complications is thought to be a result of multifactorial processes involving problems related to the material design, the surgical techniques used and disease, and patient-related factors. However, the infectious complications and mesh-tissue interactions are least studied. The aim of this article is to review any previous clinical and basic scientific evidence about the contribution of infectious and inflammatory processes to the occurrence of mesh-related complications in SUI and POP. A literature search for the relevant publications without any time limits was performed on the Medline database. There is evidence to show that vaginal meshes are associated with an unfavourable host response at the site of implantation. The underlying mechanisms leading to this type of host response is not completely clear. Mesh contamination with vaginal flora during surgical implantation can be a factor modifying the host response if there is a subclinical infection that can trigger a sustained inflammation. More basic science research is required to identify the biological mechanisms causing a sustained inflammation at the mesh-tissue interface that can then lead to contraction, mesh erosion, and pain.

PURPOSE: Clear cell, papillary cell, and chromophobe renal cell carcinomas (RCCs) have now been well characterised thanks to large collaborative projects such as The Cancer Genome Atlas (TCGA). Not only has knowledge of the genomic landscape helped inform the development of new drugs, it also promises to fine tune prognostication. METHODS: A literature review was performed summarising the current knowledge on the genetic basis of RCC. RESULTS: The Von Hippel-Lindau (VHL) tumour suppressor gene undergoes bi-allelic knockout in the vast majority of clear cell RCCs. The next most prevalent aberrations include a cohort of chromatin-modifying genes with diverse roles including PBRM1, SETD2, BAP1, and KMD5C. The most common non-clear cell renal cancers have also undergone genomic profiling and are characterised by distinct genomic landscapes. Many recurrent mutations have prognostic value and show promise in aiding decisions regarding treatment stratification. Intra-tumour heterogeneity appears to hamper the clinical applicability of sparsely sampled tumours. Ways to abrogate heterogeneity will be required to optimise the genomic classification of tumours. CONCLUSION: The somatic mutational landscape of the more common renal cancers is well known. Correlation with outcome needs to be more comprehensively furnished, particularly for small renal masses, rarer non-clear cell renal cancers, and for all tumours undergoing targeted therapy.

Purpose Imaging plays a key role throughout the renal cell carcinoma (RCC) patient pathway, from diagnosis and staging of the disease, to the assessment of response to therapy. This review aims to summarise current knowledge with regard to imaging in the RCC patient pathway, highlighting recent advances and challenges. Methods A literature review was performed using Medline. Particular focus was paid to RCC imaging in the diagnosis, staging and response assessment following therapy. Results Characterisation of small renal masses (SRM) remains a diagnostic conundrum. Contrast-enhanced ultrasound (CEUS) has been increasingly applied in this field, as have emerging technologies such as multiparametric MRI, radiomics and molecular imaging with 99mtechnetium-sestamibi single photon emission computed tomography/CT. CT remains the first-line modality for staging of locoregional and suspected metastatic disease. Although the staging accuracy of CT is good, limitations in determining nodal status persist. Response assessment following ablative therapies remains challenging, as reduction in tumour size may not occur. The pattern of enhancement on CT may be a more reliable indicator of treatment success. CEUS may also have a role in monitoring response following ablation. Response assessments following anti-angiogenic and immunotherapies in advanced RCC is an evolving field, with a number of alternative response criteria being proposed. Tumour response patterns may vary between different immunotherapy agents and tumour types; thus, future response criteria modifications may be inevitable. Conclusion The diagnosis and characterisation of SRM and response assessment following targeted therapy for advanced RCC are key challenges which warrant further research.

Due to the growing field of digital pathology, more and more digital histology slides are becoming available. This improves the accessibility, allows teleconsultations from specialized pathologists, improves education, and might give urologist the possibility to review the slides in patient management systems. Moreover, by stacking multiple two-dimensional (2D) digital slides, three-dimensional volumes can be created, allowing improved insight in the growth pattern of a tumor. With the addition of computer-aided diagnosis systems, pathologist can be guided to regions of interest, potentially reducing the workload and interobserver variation. Digital (3D) pathology has the potential to improve dialog between the pathologist and urologist, and, therefore, results in a better treatment selection for urologic patients. Electronic supplementary material The online version of this article (10.1007/s00345-018-2202-1) contains supplementary material, which is available to authorized users.

Purpose We evaluated if, during lithotripsy, bacteria may be detected in the irrigation fluid of percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). The concordance between urine culture from stone fragmentation (SFUC), bladder (BUC), renal pelvic (RPUC) and stone (SC) was analyzed. We also assessed the correlation between variables and cultures and their association with systemic inflammatory response syndrome (SIRS) and of a positive SC. Methods We included 107 patients who underwent PCNL (n = 53) and RIRS (n = 54) from January 2017 to May 2018. Samples for RPUC were obtained by renal catheterization. Stone fragments and irrigation fluid sample were sent for culture. Results SFUC was positive in 17 (15.9%), BUC in 22 (20.6%), RPUC in 26 (24.3%) and SC in 30 patients (28%). The concordance between SFUC and SC was the highest among all cultures: 94.1%. SFUC and SC grew identical microorganisms in 15/17 (88.2%) patients. Out of 17 (15.9%) patients with SIRS, 8 (7.5%) had sepsis. SFUC had the highest PPV and specificity to detect positive SC and SIRS. Previous urinary tract infection, a preoperative nephrostomy, stone diameter and composition, staghorn calculi, PCNL, positive BUC, RPUC and SFUC were predictors of infected stone. Variables that indicate complex stones, complex PCNL and an infection of the upper tract were associated with SIRS. Conclusion SFUC is technically feasible, easy to retrieve and to analyze. The spectrum of SFUC potential application in clinical practice is when is not possible to perform a SC, e.g. complete dusting or during micro-PCNL. Electronic supplementary material The online version of this article (10.1007/s00345-020-03387-6) contains supplementary material, which is available to authorized users.

Background Making healthcare treatment decisions is a complex process involving a broad stakeholder base including patients, their families, health professionals, clinical practice guideline developers and funders of healthcare. Methods This paper presents a review of a methodology for the development of urological cancer care pathways (UCAN care pathways), which reflects an appreciation of this broad stakeholder base. The methods section includes an overview of the steps in the development of the UCAN care pathways and engagement with clinical content experts and patient groups. Results The development process is outlined, the uses of the urological cancer care pathways discussed and the implications for clinical practice highlighted. The full set of UCAN care pathways is published in this paper. These include care pathways on localised prostate cancer, locally advanced prostate cancer, metastatic prostate cancer, hormone-resistant prostate cancer, localised renal cell cancer, advanced renal cell cancer, testicular cancer, penile cancer, muscle invasive and metastatic bladder cancer and non-muscle invasive bladder cancer. Conclusion The process provides a useful framework for improving urological cancer care through evidence synthesis, research prioritisation, stakeholder involvement and international collaboration. Although the focus of this work is urological cancers, the methodology can be applied to all aspects of urology and is transferable to other clinical specialties.

Introduction Stone analysis is an important part in the evaluation of patients having stone disease. This could orientate the physician toward particular etiologies. Material and methods Chemical and physical methods are both used for analysis. Unfortunately, chemical methods often are inadequate to analyze accurately urinary calculi and could fail to detect some elements into the stone. Physical methods, in counterpart, are becoming more and more used in high-volume laboratories. The present manuscript will provide a review on analytic methods, and review all the information that should be included into an appropriate morpho-constitutional analysis. Conclusion This report can supply an excellent summarization of the stone morphology and give the opportunity to find specific metabolic disorders and different lithogenic process into the same stone. Here, specific chemical types with their different crystalline phases are shown in connection with their different etiologies involved.

Background Transurethral laser prostatectomy has evolved as a viable alternative for the management of benign prostate enlargement. Since the renaissance of laser prostatectomy with the advent of the holmium:yttrium–aluminum–garnet laser in the 1990s, various lasers and subsequent procedures have been introduced. These techniques can be categorized as vaporizing, resecting, and enucleating approaches. Photoselective vaporization of the prostate (PVP) is dominated by high-power lithium triborate (LBO) crystal lasers (GreenLight XPS). The mainstay of this technique is for the treatment of small to medium prostate volumes whereas enucleating techniques, such as holmium laser enucleation of the prostate and thulium enucleation of the prostate, focus on large-volume glands. In order to perspectively “delimit” LBO into the field of large-volume prostates, we developed LBO en bloc enucleation to render it as a competing transurethral enucleating approach. Materials and methods We present a detailed stepwise progressive technique developed in Madrid, Spain, for the complete removal of the transitional zone by vapoenucleation. The steps include exposition of the prostatic capsule by PVP toward the peripheral zone, thereby identifying the anatomical limits of enucleation. Subsequently, the transitional zone is excised in a single bloc and morcellated after its placement into the bladder. Conclusion This new GreenLight en bloc enucleation technique allows to treat larger prostates than those previously treated with the PVP technique.

Non-specific immunotherapy has been for a long time a standard treatment option for patients with metastatic renal cell carcinoma but was redeemed by specific targeted molecular therapies, namely the VEGF and mTOR inhibitors. After moving treatment for mRCC to specific molecular agents with a well-defined mode of action, immunotherapy still needs this further development to increase its accuracy. Nowadays, an evolution from a rather non-specific cytokine treatment to sophisticated targeted approaches in specific immunotherapy led to a re-launch of immunotherapy in clinical studies. Recent steps in the development of immunotherapy strategies are discussed in this review with a special focus on peptide vaccination which aims at a tumor targeting by specific T lymphocytes. In addition, different combinatory strategies with immunomodulating agents like cyclophosphamide or sunitinib are outlined, and the effects of immune checkpoint modulators as anti-CTLA-4 or PD-1 antibodies are discussed. peerReviewed

Introduction: Although randomized controlled trials (RCTs) remain the gold standard for determining evidence-based clinical practices, large disease registries that enroll large numbers of patients have become paramount as a relatively cost-effective additional tool. Methods: We highlight the advantages of disease registries focusing on the example of prostate cancer and the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE™) registry. Results: CaPSURE collects approximately 1,000 clinical and patient-reported variables, in over 13,000 men that are enrolled. Thus far, CaPSURE has yielded over 130 peer-reviewed publications, with several others in press, in key areas of risk migration, practice patterns, outcome prediction, and quality of life outcomes. Conclusions: Disease registries, like CaPSURE complement RCTs and CaPSURE, have provided a means to better understand many aspects of prostate cancer epidemiology, practice patterns, oncologic and HRQOL outcomes, and costs of care across populations. Specialized observational disease registries such as CaPSURE provide insight and have broad implications for disease management and policy. © 2011 The Author(s).

Purpose Despite the positive influence of spiritual coping on the acceptance of a cancer diagnosis, higher spirituality is associated with receipt of more high intensity care at the end of life. The purpose of our study was to assess the association between spirituality and type of end-of-life care received by disadvantaged men with prostate cancer. Methods We studied low-income, uninsured men in IMPACT, a state-funded public assistance program, who had died since its inception in 2001. Of the 60 men who died, we included the 35 who completed a spirituality questionnaire at program enrollment. We abstracted sociodemographic and clinical information as well as treatment within IMPACT, including zolendroic acid, chemotherapy, hospice use, and palliative radiation therapy. We measured spirituality with the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being questionnaire (FACIT-Sp) and compared end-of-life care received between subjects with low and high FACIT-Sp scores using chi-squared analyses. Results A higher proportion of men with high (33%) versus low (13%) spirituality scores enrolled in hospice, although our analysis was not adequately powered to demonstrate statistical significance. Likewise, we saw a trend toward increased receipt of palliative radiation among those with higher spirituality (37% vs. 25%, P = 0.69). The differences in end-of-life care received among those with low and high spirituality varied little by the FACIT-Sp peace and faith subscales. Conclusions End-of-life care was similar between men with lower and higher spirituality. Men with higher spirituality trended toward greater hospice use, suggesting that they redirected the focus of their care from curative to palliative goals.

Purpose Most analyses of complications after urinary diversion are restricted to the index admission. Given the complexity of these reconstructions, readmissions occur commonly. We sought to characterize the burden and impact of readmissions in the postoperative period following urinary diversion. Methods Using 5% Medicare data for the years 1998–2005, we identified patients undergoing ileal conduit, continent, and other urinary diversions for benign and malignant indications. We examined the 90-day rates of readmission and evaluated factors associated with readmission after urinary diversion, either to the primary hospital or to a secondary facility. We assessed 90-day and 2-year mortality after urinary diversion and incorporated readmission status as a covariate in these multivariable models. Results Our study sample included 1,565 patients, of whom 491 patients (31%) were readmitted within 90 days of their urinary diversion. Patients readmitted after urinary diversion had higher comorbidity count than those not readmitted (59% of those readmitted with comorbidity count at least 1 versus 50% of those not readmitted, P = 0.002). Other clinical and demographic characteristics did not differ by readmission status (P > 0.12 for age, race, type of urinary diversion, and primary diagnosis). Complication rates were higher in readmitted patients than those not readmitted; 2-year mortality was associated with 90-day readmission status—18.8% of readmitted versus 12.8% of not readmitted patients died within 2 years of surgery (P = 0.003). Conclusions Readmissions occur commonly after urinary diversion. Many readmitted patients have complications of complex surgery managed at secondary hospitals, which may portend a quality concern that merits further study.

Purpose The aim of this retrospective study was to evaluate in a historical series of patients whether morphological changes of the urinary tract imaged on intravenous urography (IVU) are associated with clinical or urodynamic data. Methods During a 1-year period, every man 45 years or older with lower urinary tract symptoms suggestive of benign prostatic hyperplasia was systematically evaluated with multi-channel computer-urodynamic investigation and IVU. Men with urinary retention, known bladder stones or diverticula, severely impaired renal function, or allergy to iodine contrast media were excluded. Structural alterations of the urinary tract were correlated with clinical and urodynamic data using logistic regression analysis. Results Data on 203 consecutive patients were available for analysis. Multivariate analysis demonstrated that the “fish-hook” configuration of the distal ureter (also known as “hockey-stick”, or “J-shaped” ureter) was the only sign significantly associated with benign prostatic obstruction (BPO) (odds-ratio 3.64; 95% confidence interval 1.69–7.83; P

Objectives To study the results of chemotherapy combined with intravesical hyperthermia in patients with mainly BCG-failing carcinoma in situ (CIS). Methods Patients with histologically confirmed CIS were included retrospectively. Outpatient thermochemotherapy treatment was done with mitomycin-C (MMC) and the Synergo® system SB-TS 101 (temperature range between 41 and 44°C), weekly for 6–8 weeks, followed by 4–6 sessions every 6–8 weeks. Results Fifty-one patients were treated between 1997 and 2005 from 15 European centers. Thirty-four were pre-treated with BCG. Mean age was 69.9 years. Twenty-four patients had concomitant papillary tumors. The mean number of hyperthermia/MMC treatments per patient was 10.0. Of the 49 evaluable patients 45 had a biopsy and cytology proven complete response. In two patients CIS disappeared, but they had persistent papillary tumors. Follow-up of 45 complete responders showed 22 recurrences after a mean of 27 months (median 22): T2 (4), T1 (4), T1/CIS (1), CIS (5), Ta/CIS (2), Ta (5) and Tx (1). Side effects (bladder complaints) were generally mild and transient. Conclusions In patients with primary or BCG-failing CIS, treatment with intravesical hyperthermia and MMC appears a safe and effective treatment. The initial complete response rate is 92%, which remains approximately 50% after 2 years.

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care. In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer. From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements. This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

Purpose: This paper explores the feasibility of a new therapy for the treatment of hypospadias patients. Hypospadias is a very common congenital malformation of male genitals, with very high rate of recurrences after surgery. The field of regenerative medicine, which offers innovative solutions for many pathologies, still does not offer reliable solution for this pathology. Here, we propose quality, safety, and clinical feasibility assessment for an oral mucosa advanced therapy medicinal product (ATMP) grown on a biocompatible scaffold for a clinical study on urethral reconstruction of hypospadias patients. Methods: Urethral and oral mucosal epithelia from donor biopsies were cultivated between two fibrin layers, under clinical-grade conditions for cell and tissue characterization and comparison, aimed at tissue engineering. In addition, single-clone analyses were performed to analyze gene expression profiles of the two epithelia by microarray technology. Results: Oral mucosa appeared suitable for urethral reconstruction. The resulting ATMP was proven to maintain stem cells and regenerative potency. The preclinical safety studies were performed on human tissues to assess abnormalities and tumorigenicity, and confirmed the safety of the ATMP. Finally, the patient selection and the clinical protocol for the upcoming clinical trial were defined. Conclusions: Against this backdrop, in this paper, we are proposing a new reproducible and reliable ATMP for the treatment of hypospadias.

Purpose Nodal recurrent prostate cancer (PCa) after primary radical treatment represents a heterogeneous entity with many treatment options. In some cases, surgical removal of metastatic nodes seems to improve cancer control and delay systemic treatments. The objectives of this study were to analyze the available literature on salvage lymphadenectomy for the treatment of nodal recurrent PCa and to elucidate the real oncological benefit deriving from this procedure. Methods A PubMed search was performed using the following terms: prostate cancer, metastatic, oligometastatic, salvage lymphadenectomy, salvage lymph node dissection, salvage lymph node excision, and cytoreductive surgery. We included in the study all papers on salvage lymphadenectomy in nodal recurrent PCa, with no temporal limits. In addition, several papers addressing cytoreductive surgery and the biology of oligometastatic disease, published in different medical and basic research journals, were included. Results Salvage lymphadenectomy is still characterized by a lack of standardization in patient selection and surgical template. Its primary objectives are to prolong progression-free survival and to delay the need for systemic therapy. The improvements in preoperative imaging techniques in conjunction with the wide use of minimally invasive surgery have generated growing interest in this procedure. Conclusion Salvage lymphadenectomy is a promising treatment approach; however, its real oncological benefit is still far from proven. Prospective randomized trials need to be designed to improve understanding of this issue.

INTRODUCTION: The genomic revolution has transformed our understanding of urinary tract infection. There has been a paradigm shift from the dogmatic statement that urine is sterile in healthy people, as we are becoming forever more familiar with the knowledge that bacterial communities exist within the urinary tracts of healthy people. Metagenomics can investigate the broad populations of microbial communities, analysing all the DNA present within a sample, providing comprehensive data regarding the state of the microenvironment of a patient's urinary tract. This permits medical practitioners to more accurately target organisms that may be responsible for disease-a form of 'precision medicine'. METHODS AND RESULTS: This paper is derived from an extensive review and analysis of the available literature on the topic of metagenomic sequencing in urological science, using the PubMed search engine. The search yielded a total of 406 results, and manual selection of appropriate papers was subsequently performed. Only one randomised clinical trial comparing metagenomic sequencing to standard culture and sensitivity in the arena of urinary tract infection was found. CONCLUSION: Out of this process, this paper explores the limitations of traditional methods of culture and sensitivity and delves into the recent studies involving new high-throughput genomic technologies in urological basic and clinical research, demonstrating the advances made in the urinary microbiome in its entire spectrum of pathogens and the first attempts of clinical implementation in several areas of urology. Finally, this paper discusses the challenges that must be overcome for such technology to become widely used in clinical practice.

Female urethral stricture disease is a rare entity. To date, its diagnosis and treatment have been poorly studied, with small numbers, and variable definitions of success. With growing interest in this area of reconstructive urology, there is an increased number of surgical techniques. In this article, we review current trends, definitions, etiologies and surgical techniques available for management of FUSD. We completed a review of publications in: English; Pubmed, and Google scholar. Key words identified for review were, female urethra stricture, female urethroplasty and female urethral dilation, female pelvic fracture, and female urethral reconstruction. Papers were reviewed, and references of relevant papers reviewed. Iatrogenic injury is the most common cause of female urethral stricture disease. Assessment requires a thorough patient history, examination and either flexible cystoscopy and/or fluoroscopic urodynamics to determine the most appropriate surgical approach for stricture repair. Multiple open urethroplasty techniques are described with various grafts and flaps, with good medium-term success. Minimally invasive techniques remain well-employed but have poor long-term success, with increased failure with multiple attempts at treatment. Female urethral stricture disease is a complex clinical entity that requires a measured and thorough evaluation. Individualized approach should be undertaken reviewing the patient’s symptoms, the stricture’s etiology, surrounding vaginal tissue health and stricture location. Promising medium-term success rates with vaginal flaps and buccal mucosal graft urethroplasty have been reported, with disappointing long-term results from repeated urethral dilation. Further research comparing techniques and defining successful long-term outcomes is required.

Purpose To look at the bibliometric publication trends on ‘Urolithiasis’ and aspects of treatment and training associated with it over a period of 16 years from 2000 to 2015. To this end, we conducted this study to look at the publication trends associated with urolithiasis, including the use of simulation, laser technology, and all types of interventions for it. Materials and methods We performed a systematic review of the literature using PubMed over the last 16 years, from January 2000 to December 2015 for all published papers on ‘Urolithiasis’. While there were no language restrictions, English language articles and all non-English language papers with published English abstracts were also included. Case reports, animal and laboratory studies, and those studies that did not have a published abstract were excluded from our analysis. We also analyzed the data in two time periods, period-1 (2000–2007) and period-2 (2008–2015). Results During the last 16 years, a total of 5343 papers were published on ‘Urolithiasis’, including 4787 in English language and 556 in non-English language. This included papers on URS (n = 1200), PCNL (n = 1715), SWL (n = 887), open stone surgery (n = 87), laparoscopic stone surgery (n = 209), pyelolithotomy (n = 35), simulation in Endourology (n = 82), and use of laser for stone surgery (n = 406). When comparing the two time periods, during period 2, the change was +171% (p = 0.007), +279% (p

Purpose “Point-of-Care Ultrasound” (POCUS) is now a familiar term. Although the European Federation of Societies for Ultrasound in Medicine and Biology (ESFUMB) published a position paper about its usage (Nielsen et al. in Ultraschall Med 40(1):30–39. https://doi.org/10.1055/a-0783-2303, 2019), there has not been much scientific focus on its utility in uro-nephrological clinical practice thus far. The aim of this study was to evaluate the present usage of pocket ultrasound devices at the bedside. Methods 27 investigators (all medical doctors with at least 6 months of experience in sonography) performed 280 bedside examinations using a pocket ultrasound device for common clinical issues. Results The most frequent indications included evaluation of hydronephrosis (147), volume management including assessment of dimension of the vena cava inferior (IVC) (195), detection of pleural, pericardial and abdominal effusions (113) as well as residual urine (52). In 90%, specific clinical questions were effectively answered by the pocket ultrasound device alone. Conclusions POCUS can be useful in the uro-nephrological field. In the hands of an experienced investigator, it saves time and, when it is realised that departmental ultrasound is not cheap, there is also an economic benefit with applicability within both inpatient and outpatient clinic settings. While acknowledging its technical limits, pocket ultrasound devices may nevertheless be helpful in targeted situations for triage or for bedside follow-up exams after earlier high-end ultrasound-based diagnosis.

Purpose The purpose of this paper is to present evidence regarding the associations between smoking and the following urologic cancers: prostate, bladder, renal, and upper tract urothelial cancer (UTUC). Methods This is a narrative review. PubMed was queried for evidence-based analyses and trials regarding the associations between smoking and prostate, bladder, renal, and UTUC tumors from inception to September 1, 2022. Emphasis was placed on articles referenced in national guidelines and protocols. Results Prostate—multiple studies associate smoking with higher Gleason score, higher tumor stage, and extracapsular invasion. Though smoking has not yet been linked to tumorigenesis, there is evidence that it plays a role in biochemical recurrence and cancer-specific mortality. Bladder—smoking is strongly associated with bladder cancer, likely due to DNA damage from the release of carcinogenic compounds. Additionally, smoking has been linked to increased cancer-specific mortality and higher risk of tumor recurrence. Renal—smoking tobacco has been associated with tumorigenesis, higher tumor grade and stage, poorer mortality rates, and a greater risk of tumor recurrence. UTUC—tumorigenesis has been associated with smoking tobacco. Additionally, more advanced disease, higher stage, lymph node metastases, poorer survival outcomes, and tumor recurrence have been linked to smoking. Conclusion Smoking has been shown to significantly affect most urologic cancers and has been associated with more aggressive disease, poorer outcomes, and tumor recurrence. The role of smoking cessation is still unclear, but appears to provide some protective effect. Urologists have an opportunity to engage in primary prevention by encouraging cessation practices.

This paper provides an overview of the scientific and practical aspects of assessing health-related quality of life (HRQL). The paper provides a brief overview of developments in the field and then discusses the definition of HRQL. The different types of HRQL measure available to researchers are described, with specific references to urology measures. The paper then focuses on the conceptual and methodological difficulties inherent in patient-centred measures and describes the various means of ensuring scientific soundness in such measures. It concludes that HRQL measures offer much potential to those interested in patient outcomes but that their widespread introduction into research and practice must be carried out with caution.

The objective of this paper was to discuss the psychological impact of active surveillance (AS) for prostate cancer (PCa) and the resulting implications of psychological wellbeing for treatment decision making and acceptance of AS protocols. Qualitative and quantitative research in the area of anxiety, depression, and distress is discussed drawing from PCa literature as well other health conditions from which parallels can be drawn. Attention is given to the role of the clinician in treatment decision making, including the value of information provision, and perceived trust in the AS as a management approach. Given that research is conflicted regarding the psychological impact of AS for PCa, it is suggested that focus shifts away from debate of the ‘true’ experience of AS rather researchers and clinicians should seek to identify the factors associated with positive and negative psychological response to diagnosis and AS to improve psychological and physical outcomes. Recommendations for clinical practice are discussed.

Molecular biology has altered the face of biomedical research. Due to new techniques in molecular biology, our knowledge of pathological processes has grown exponentially over the last decades. Today, cancer research has become a multidisciplinary task, requiring basic scientists as well as clinicians. However, only when scientists and clinicians bridge the gap between laboratory and clinic, a rapid translation of the experimental Wndings to the clinic will take place. For a long time, progression of prostate cancer (PCa) was explained with loss of androgen receptor (AR) expression. After years of research, it became clear that the AR plays a crucial role in recurrent PCa. New therapies that interfere with androgen signalling have been developed after many years of performing laboratory research on the AR. In the following special issue “Molecular aspects of prostate cancer”, the World Journal of Urology oVers a unique collection of reviews and original papers highlighting recent developments in PCa research. Prostate cancer (PCa) is the second most frequently diagnosed cancer worldwide [1]. While treatment of organconWned PCa involves radical prostatectomy or radiation therapy, current treatment for advanced PCa is mainly based on androgen ablation therapies like chemical or surgical castration and/or the application of anti-androgens. One main obstacle in the treatment of advanced PCa is the development of castration-resistant prostate cancer (CRPC) cells following androgen ablation therapy. In this special issue, two comprehensive reviews by Nadiminty et al. and Hodgson et al. summarize our current knowledge about the molecular mechanisms leading to sustained AR signalling in CRPC [2, 3]. In addition, Culig and Santer [4] present a very informative survey on the emerging Weld of AR-co-activators and their role in the initiation and progression of PCa. A further article of Jain et al. [5] highlights the importance of NFB-signalling for the regulation of apoptotic pathways as well as AR signalling. The series of reviews is completed by a paper of Marianne Sadar [6] summarizing the latest advances in the development of small-molecule inhibitors of the AR. Classical as well as second-generation anti-androgens like MDV3100 or ARN-509 target the ligand-binding domain situated in the C-terminus of the AR. With special emphasis on novel AR-antagonists targeting the N-terminal AR-transactivation domain, Sadar presents a novel revolutionary generation of AR-antagonists, able to inhibit deregulated full-length AR as well as constitutively active, C-terminally truncated AR-variants recently identiWed in CRPC cells [7, 8]. The reviews of this special issue are complemented by a series of original articles. On the basis of ID4 expression, Vinarskaja et al. [9] document the limits and pitfalls of techniques used for the detection of methylation-based DNA-markers. In a preliminary study, the team of Stope et al. [10] provides Wrst experimental evidence that the small heat shock protein HSP27 is not only involved in folding and stability of client proteins but has also an impact on the regulation of messenger RNA in PCa cells. Finally, Streicher et al. [11] present an experimental model system designed to select next-generation AR-antagonists targeting the N-terminus of the AR as described by Sadar in this issue. M. V. Cronauer (&) Department of Urology, University of Ulm, Prittwitzstrasse 43, 89075 Ulm, Germany e-mail: marcus.cronauer@uni-ulm.de

Functional status and physical independence play a key role in terms of quality of life, access to treatment, and continuity of care. Surgery, a central component of cancer treatments, leads to detrimental effects on functional capacity, which can be peculiarly relevant in vulnerable patients undergoing major procedures. Prehabilitation is a multidisciplinary intervention that uses the preoperative period to prevent or attenuate treatment-related functional decline and its subsequent consequences. This paper narratively reviews the rationale and the evidence of prehabilitation for uro-oncologic surgery. A narrative review was conducted in August 2020, aiming to: (1) identify and discuss the impact of modifiable determinants of postoperative outcomes in urology and (2) review randomized controlled trials (RCT) exploring the role of preoperative exercise, nutrition, and psychological interventions in uro-oncologic surgery. Eight RCTs on preoperative conditioning interventions met the inclusion criteria, focusing on radical cystectomy for bladder cancer (RC) and radical prostatectomy for prostate cancer (RP). There is strong evidence that poor physical, nutritional and psychosocial status negatively impacts on surgical outcomes. Single modality interventions, such as preoperative exercise or nutrition alone, had no effect on ‘traditional’ surgical outcomes as length of stay or complication. However, multimodal approaches targeting postoperative functional status have shown to be effective and safe. There is initial evidence on the effectiveness and safety of multimodal prehabilitation in preserving functional capacity following RC and RP. However, to date, outcomes such as complications and length of stay seem to be not affected by prehabilitation.

In this paper, we investigated whether cholecalciferol supplementation may increase the risk of stone recurrence in patients with calcium nephrolithiasis and Vitamin D deficiency. Thirty-three stone formers (56 ± 17 years old, 12 males) with 25(OH)D 1 mean supersaturation. Cholecalciferol was prescribed as oral bolus of 100,000–200,000 IU, followed by weekly (5000–10,000 IU) or monthly (25,000–50,000 IU) doses. Calcium intake varied between 800 and 1000 mg/day. In urine, total nitrogen (TNE) was taken as an index of protein intake, sodium as a marker of dietary intake, and net acid excretion (NAE) as an index of acid–base balance. TNE, sodium, and NAE did not change during the study (p = ns). Compared to baseline values, after cholecalciferol, both serum calcium and phosphate did not vary (p = ns); 25(OH)D increased from 11.8 ± 5.5 to 40.2 ± 12.2 ng/mL (p

Penile cancer is a rare disease in developed countries and raises several diagnostic and therapeutic dilemmas. They range from the morbidity of treating the primary penile tumor with the potential for signiWcant loss of “quality of life,” to management of the inguinal region where literally one’s life could be jeopardized based upon disease burden. For this topic of World Journal of Urology, dedicated to penile cancer, we brought together a group of authors active in the Weld to address contemporary issues and advances in penile cancer. There are well known diVerences in the incidence of penile cancer, pointing to various etiological factors. The paper of Bleeker and coworkers explores in depth the current knowledge on the epidemiology and pathogenesis. Expanding their well known work on HPV in cervical cancer, they have used their knowledge to explore the role of HPV in penile cancer. Most important is their Wnding of Xat penile lesions as the presumed most infectious lesion, most probably responsible for the transmission of HPV. More insight into prognostic factors in order to tailor therapy is a continuous scientiWc endeavor in oncological surgery with very practical consequences. The Weld is moving away from clinical prognosticators to molecular ones. The paper of Muneer summarizes the literature on molecular prognostic factors. Unfortunately, so far, no clearcut prognostic factor has emerged from the numerous factors assessed to date. More work is needed in this Weld to better categorize patients in order to tailor therapy to risk, for the present pathological prognosticators still dominate risk assessment. In elegant studies, Cubilla has shown the various growth patterns in penile cancer such as perineurial invasion, vascular invasion, and high histological grade are the most important adverse pathological prognostic factors. While amputation with its ensuing physical and psychological consequences had been standard therapy, penis preservation is now being used more commonly. In a paper from London, combining the experience of two large referral centers, Hegarty et al. emphasize the role of penis preserving strategies. In T1 and most T2 tumors they give examples of a variety of penis preserving modalities aimed at maximal tissue preservation while not compromising oncological safety. In addition, radiation therapy is considered a penis preserving strategy. Crook et al. present the world literature and their personal series in this treatment modality. The presence and extend of lymph node metastasis can drastically alter one’s prognosis in penile cancer. Inguinal lymphadenectomy, while providing reliable pathologic staging, is morbid and in the setting of patients without metastasis provides no beneWt. It has been recognized for some time that histopathologic factors in the primary tumor can stratify one’s risk for lymph node metastasis. In their article, Ficarra et al. review the current status of the ability of such factors to stratify a patient’s likelihood of inguinal metastasis. In addition, they discuss the ability of newly developed nomograms to predict both nodal status and survival based upon clinical parameters. DeWning both non and minimally invasive staging modalities is critical to C. A. Pettaway (&) Department of Urology and Cancer Biology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1373, Houston, TX 77030, USA e-mail: cpettawa@mdanderson.org

The heterogeneity of prostate cancer has made imaging modalities of crucial importance in this disease. Accurate diagnosis and staging of the volume and extent of disease, especially in advanced and metastatic prostate cancer, can help to tailor the timing and modalities of treatment. While MRI has been effective in the detection of significant prostate cancer, its use in the identification and quantification of extraprostatic disease is limited. This gap is now being filled by PSMA PET. PSMA PET scans have now been shown to have a role in all stages in the prostate cancer journey. Emerging evidence has shown its promise in primary staging, restaging and theranostics. In this paper, we review the evidence for the use of PSMA PET in the various stages of prostate cancer, from initial diagnosis to advanced metastatic disease where other systemic treatments have failed.

Before English took the lead as the prime scientific language among northern European urologists and surgeons, German was widely regarded as the “lingua franca”. This shift has to date not been systematically reconstructed. This article provides insights into the question how political and social factors influence how physicians communicate with each other, what they read, and how the constellations of international scientific communities in medicine change over time. Through a language analysis of more than 2000 articles, including their references, in major Swedish medical journals as well as surgical doctoral dissertations defended at Swedish universities, this paper explores scientific language trends during the first half of the twentieth century among Swedish physicians for the first time on a large scale. The study shows that Swedish urologists and surgeons generally did not switch to English during the years immediately after the First World War, as has been documented in other countries. After a decrease during the first 10 years after the First World War, the German language dominated among Swedish urologists and surgeons from the 1930s until the early 1940s, when English first dominated at large. The rapidity of this process shows that almost all surgical researchers had changed from German to English within just a few years.

Renal tumor biopsy (RTB), as distinct from the more common renal biopsy for medical renal disease, is an option for patients with renal masses. It is mainly used for small renal masses (SRM) but it may also be indicated for larger masses and even in the presence of metastatic disease. Its main indication in SRM is to avoid intervention for benign kidney tumors but increasingly enables more personalized treatment for kidney cancer patients. The objective of this paper is to provide a comprehensive review of the most recent literature available for RTB including the indications, the technique and also the possible complications. The urological community continues to optimize the indications for RTB. Non-operative treatment modalities, such as active surveillance, ablative modalities, and immunotherapy, may have different results influenced by tumor histology. Continuing concern regarding complications and accuracy and, therefore, the utility of RTB has been addressed. Recent reports support the potential benefit of RTB, safely avoiding a significant number of interventions with good results and minimal complications. Urologists should be aware of the benefits of RTB and develop experience with this technique to optimize the results. This diagnostic strategy should be discussed with patients and adopted as it has been with other solid tumors.

The mid-urethral synthetic sling (MUS) procedure has become the standard of care for treatment of female stress urinary incontinence. However, a small number of patients will have complications following MUS including failure, obstructive voiding, sling erosion, or chronic pain. This paper discusses the role of 2D and 3D ultrasound imaging in the evaluation of the female patient with complications following placement of a synthetic mid-urethral sling. The MUS is easily visualized as an echogenic structure on ultrasound and can be imaged by transperineal, transvaginal and introital approaches. Ultrasound allows dynamic assessment of the sling and can assist in the diagnosis of sling failure, obstruction, erosion and mesh related pain. Pelvic floor ultrasound has an emerging role in the assessment of complications following MUS surgery. 3D ultrasound can assist the clinician in assessment of the complex patient with multiple slings or meshes in situ.

PURPOSE: The aim of this review was to provide current best evidence for evaluation, dietary, and medical management of patients with urolithiasis.METHODS: Literature addressing evaluation, dietary, and medical management of urolithiasis was searched. Papers were analyzed and rated according to level of evidence (LOE), whereupon a synthesis of the evidence was made. Grade of recommendation (GOR) was judged from individual clinical experience and knowledge of the evidence according to the Oxford Centre for Evidence-based Medicine.RESULTS: It is obvious that different stone diseases influence the life of stone-forming individuals very differently, and that evaluation and medical management should be personalized according to risk of recurrence, severity of stone disease, presence of associated medical conditions, and patient's motivation. With regard to evaluation, dietary and medical management of patients with urolithiasis evidence from the literature suggest that selective metabolic evaluation may lead to rational dietary and medical management. Statements based on LOE and GOR are provided to guide clinical practice.CONCLUSION: The provided evidence for evaluation of patients with urolithiasis aims at defining patients at high risk for recurrent/complicated stone disease. Based on this approach, evidence-based dietary and medical management regimes are suggested.