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

Purpose: Comparing post-radical prostatectomy erectile function rates among different techniques has always been a challenge in urology. This difficulty is due to the heterogeneity of studies, mainly in relation to the type of erectile function classification criteria used. The aim is to apply a new evidence-gathering methodology, called reverse systematic review, to compare erectile function rates among retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robot-assisted radical prostatectomy, considering the diversity of classification criteria., Methods: A search was carried out in eight databases between 2000 and 2020 through systematic review studies referring to retropubic radical prostatectomy, laparoscopic radical prostatectomy, or robot-assisted radical prostatectomy (80 systematic reviews). All references used in these systematic reviews were captured by referring to 910 papers in a global database called EVIDENCE. A total of 268 studies related to post-prostatectomy erectile function rates were selected for the final analysis, totaling 465 cohorts or reports referring to 131,350 patients., Results: Note that, 119 (25.6%) reports for retropubic radical prostatectomy, 143 (30.7%) reports for laparoscopic radical prostatectomy, and 203 (43.7%) reports for robot-assisted radical prostatectomy were found. Mean overall erectile function rates, respectively for retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robot-assisted radical prostatectomy, were: 16%, 12%, and 35% at 1 month, 22%, 26%, and 42% in 3 months; 30%, 44%, and 54% at 6 months, 41%, 55%, and 59% at 12 months, and 58%, 52%, and 67% at more than 18 months. The most used erectile function criterion was Erection Sufficient for Intercourse (74.1%), followed by Sexual Health Inventory for Men > 21 (5.5%), and Sexual Health Inventory for Men > 16 (3.7%). Erection Sufficient for Intercourse showed the lowest discrepancy in erectile function rates in each period compared to the global average, for each technique, demonstrating less ability to influence the final results, favoring any of the techniques., Conclusions: The reverse systematic review demonstrated that the robot-assisted radical prostatectomy showed higher rates of erectile function recovery at all times analyzed (1->18 months), in relation to the retropubic radical prostatectomy and laparoscopic radical prostatectomy. The Erection Sufficient for Intercourse criterion was the most used in the literature and showed the lowest bias capable of influencing the results and favoring any of the techniques and might be the fairest option for future comparisons., (© 2024 American Society of Andrology and European Academy of Andrology.)

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

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

Inconsistent engagement in pelvic floor muscle exercise (PFME) among patients with prostate cancer (PC) following radical prostatectomy may have contributed to varying effectiveness in improving urinary incontinence across studies. Identifying factors influencing engagement can help develop effective interventions to maximize participation, enhance urinary function and improve quality of life (QoL). This scoping review aims to systematically search for factors influencing PFME engagement among post radical prostatectomy patients managing urinary incontinence. Eligible publications in English were identified from various databases, including PubMed, CINAHL, ProQuest, PsycINFO and Scopus. A health science librarian was consulted to assist in formulating search terms, encompassing PC, PFME terms and influencing factors terms. We employed Colandrapp™ for data extraction, focusing on key themes such as study characteristics, PFME education and training, recommended sessions, engagement rates and factors influencing PFME engagement following radical prostatectomy. Results were presented in tables and supplemented by a narrative discussion addressing gaps in research knowledge. The synthesis drew from a diverse body of literature, blending quantitative and qualitative approaches, to contribute to a comprehensive understanding of PFME engagement factors. Twelve papers, based on 10 studies published between 2011 and 2018, met our inclusion criteria. The reviewed studies primarily employed longitudinal quantitative designs, except for one study that utilized a mixed‐method design. Only three studies incorporated theories to guide the selection of potential factors influencing PFME engagement. The factors examined across the reviewed studies encompassed aspects related to the patient–partner relationship, patient's action control, planning (dyadic or individual), self‐efficacy, perceived urinary incontinence and the patient–provider relationship. We observed conflicting findings regarding the factors influencing PFME engagement across studies. Our review underscores the importance of theory‐informed studies using rigorous methodology and precise theoretical and operational definitions of potential factors. Such studies can help pinpoint the most influential factors to enhance PFME engagement and, ultimately, improve symptoms and QoL for PC patients. The scoping review also showed critical implications for nursing practice. Nurses should develop individualized and culturally sensitive interventions, integrate health behaviour change theories, assess patient–partner relationships and action control and consider intention's mediating role in the enhancement of PFME engagement following radical prostatectomy. [ABSTRACT FROM AUTHOR]

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

Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high‐risk disease. However, post‐prostatectomy urinary incontinence remains a major functional side‐effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre‐ and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post‐prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging‐based articles evaluating the pelvic floor and surrounding structures pre‐ and/or postradical prostatectomy to predict post‐prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post‐prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single‐center nature of studies, and the heterogeneity in patient populations and methodologies used. [ABSTRACT FROM AUTHOR]

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

Advanced screening programmes have led to an increased incidence of prostate cancer worldwide. Prostate Cancer is currently the most common site of male cancers worldwide; accounting for 21% of all male cancers in Ireland. This article presents an in-depth review of the available evidence (January 1997 to April 2007), which directly compares outcomes (in terms of urinary function, bowel function, sexual function, quality-of-life (QOL) outcomes and survival statistics) post radical prostatectomy versus a conservative watch-and-wait approach for the treatment of clinically localized prostate cancer. The aim of this paper is to equip health-care professionals with the best available research evidence. Best research evidence is a component of evidence-based practice, which is very much ‘in vogue’ in health care today. The authors recommend that practitioners utilize this, the available evidence in combination with their clinical expertise and their patients’ opinions in order to assist these patients’ to make wise and informed treatment decisions. As this paper will demonstrate, the treatment chosen can have important implications in terms of patient outcomes. Therefore, making an informed decision early on can prevent any regret at a later stage. Overall this review of the literature revealed significant disparity in terms of which treatment option is more favourable. Patients overall are faced with a difficult dilemma when making this treatment decision – to live longer at the expense of potential erectile dysfunction and possible urinary incontinence or to live for a potentially shorter time without these adverse consequences. [ABSTRACT FROM AUTHOR]

Mail or fax the Answer Sheet to the College office: Mr. Wallace Lam The College of Surgeons of Hong Kong Hong Kong Academy of Medicine Jockey Club Building Room 601, 99 Wong Chuk Hang Road, Aberdeen, Hong Kong. Almost 3000 patients with prostate cancer were treated 2.Concerning the patients and the prostate cancer with radical prostatectomy performed in the review:A. Starting from November issue 2008, articles would be chosen as CME papers from each issue of the Surgical Practice. [Extracted from the article]

Introduction: Variation in target volume delineation from clinical trial protocols has been shown to contribute to poorer patient outcomes. A clinical trial quality assurance framework can support compliance with trial protocol. Results of the TROG 08.03 RAVES benchmarking exercise considering variation from protocol, inter-observer variability and impact on dosimetry are reported in this paper.Methods: Clinicians were required to contour and plan a benchmarking case according to trial protocol. Geometric pjmirometers including volume, Hausdorff Distance, Mean Distance to Agreement and DICE similarity coefficient were analysed for targets and organs at risk. Submitted volumes were compared to a STAPLE and consensus 'reference' volume for each structure. Dosimetric analysis was performed using dose volume histogram data.Results: Benchmarking exercise submissions were received from 96 clinicians. In total 205 protocol variations were identified. The most common variation was inadequate contouring of the CTV in 84/205 (41%). The CTV volume ranged from 65.3 to 193.1 cm3 with a median of 113.2 cm3 . The most common dosimetric protocol variation related to rectal dosimetry. The mean submitted rectal volume receiving 40 Gy and 60 Gy, respectively, was 56.14% ± 5.55% and 30.25% ± 6.15%. When corrected to the protocol defined length the mean rectal volume receiving 40 Gy was 60.8% ± 7.92%, while the volume receiving 60 Gy was 33.86% ± 8.21%.Conclusion: Variations from protocol were found in the RAVES benchmarking exercise, most notably in CTV and rectum delineation. Inter-observer variability was evident. Incorrect delineation of the rectum impacted on dosimetric compliance with protocol. [ABSTRACT FROM AUTHOR]

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

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

Background: With increasing numbers of younger men being diagnosed with prostate cancer and subsequently undergoing radical prostatectomy, there is an increasing focus on quality of life postoperatively, especially potency. In patients with locally advanced disease, it has been suggested that use of nerve grafts at the time of radical prostatectomy may improve potency. The technique was first described in 1999 and several papers have been published about its utility. However, there is still controversy over its use because of the lack of any large, blinded trials, the anatomy of the cavernous nerves and the necessity of excising the neurovascular bundles (especially bilaterally). In addition, the results achieved with nerve grafting, a procedure not without significant morbidity and mortality, do not exceed those produced by surgeons carrying out nerve-sparing procedures. Results: In the published work reviewed, erections sufficient to produce vaginal penetration following unilateral nerve grafting (with contralateral nerve sparing) were evident in 41.7–63.6% of patients. This is similar to the rates of 23–64% with unilateral nerve sparing alone. The rates of erectile function sufficient to produce vaginal penetration following bilateral nerve grafting were 34–72%, whereas it is widely accepted that very few men without nerve grafting would have any degree of potency. Conclusions: Currently, there does not appear to be a widespread role for nerve grafting at the time of radical prostatectomy. [ABSTRACT FROM AUTHOR]

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

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

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

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

The aim of the present paper was to assess trends in clinician's utilization of urgency categories for elective surgery. The present paper reviews the additions to the Victorian elective surgery waiting list for hip replacement and prostatectomy as recorded by the Elective Surgery Information System database. Review of general trends in utilization over two separate 12 month periods were undertaken. There is inconsistency in categorization of patients referred to the waiting list for hip joint replacement and prostatectomy. An increasing trend to categorize patients as semi-urgent (category 2) in preference to non-urgent (category 3) emerged over this period (category creep). Semi-urgent cases might be competing for access within the category 2 band with less urgent cases. There seems to be an increasing imbalance between demand for and availability of elective surgery for lower urgency elective surgical procedures. This imbalance, characterized by lengthening waiting times, means that not all patients will receive treatment within the clinically recommended waiting times. The variable approach to categorization of urgency suggests that the process lacks objectivity and consensus. Simple clinical tools to assist prioritization are currently being evaluated in Victoria (Australia) and other countries. [ABSTRACT FROM AUTHOR]

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

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

These guidelines cover a wide range of topics from prostate cancer epidemiology to palliative care. Questions arising in daily clinical practice have been extracted and formulated as clinical questions. In the 4 years since the previous edition, there have been major changes - for example, robot-assisted prostatectomy has rapidly come into widespread use, and new hormones and anticancer drugs have been developed for castration-resistant prostate cancer. In response to these developments, the number of fields included in this guideline was increased from 11 in the 2012 edition to 16, and the number of clinical questions was increased from 63 to 70. The number of papers identified in searches of the existing literature increased from 4662 in the first edition, published in 2006, to 10 490 in the 2012 edition. The number of references has reached 29 448 just during this review period, indicating the exponential increase in research on the topic of prostate cancer. Clinical answers have been prepared based on the latest evidence. Recommendation grades for the clinical answers were determined by radiologists, pathologists, and other specialists in addition to urologists in order to reflect the recent advances and diversity of prostate cancer treatment. Here, we present a short English version of the original guideline, and overview its key clinical issues. [ABSTRACT FROM AUTHOR]

Background: The optimal treatment approach for low‐risk prostate cancer (LRPC) remains controversial. While active surveillance is an increasingly popular option, definitive local treatments, including radical prostatectomy (RP), external beam radiotherapy (EBRT), and prostate seed implantation (PSI), are also commonly used. This study aimed to evaluate the survival outcomes of patients with LRPC using a large patient population from the National Cancer Database (NCDB). Methods: We analyzed data from 195,452 patients diagnosed with LRPC between 2004 and 2015 using the NCDB. Patients were classified based on their treatment modalities, including RP, EBRT, PSI, or no local treatment (NLT). Only patients with Charlson–Deyo comorbidity scores of 0 or 1 were included to ensure comparability. Propensity score analysis was used to balance the treatment groups, and the accelerated failure time model was used to analyze the survival rates of the treatment groups. Results: After a median follow‐up of 70.8 months, 24,545 deaths occurred, resulting in an all‐cause mortality rate of 13%. RP demonstrated a survival benefit compared with NLT, particularly in patients younger than 74 years of age. In contrast, radiation treatments (EBRT and PSI) did not improve survival in the younger age groups, except for patients older than 70 years for EBRT and older than 65 years for PSI. Notably, EBRT in patients younger than 65 years was associated with inferior outcomes. Conclusion: This study highlights the differences in survival outcomes among LRPC treatment modalities. RP was associated with improved survival compared to NLT, especially in younger patients. In contrast, EBRT and PSI showed survival benefits primarily in the older age groups. NLT is a reasonable choice, particularly in younger patients when RP is not chosen. These findings emphasize the importance of individualized treatment decisions for LRPC management. [ABSTRACT FROM AUTHOR]

Urinary incontinence (UI) is a common complication of prostatectomy. International guidelines suggest using pelvic floor muscle training (PFMT) as a first‐line intervention (grade A) to help patients reduce the involuntary urine leakages. In the literature it is hard to find a complete exercise scheme, with full details (e.g. body position during PFMT, how to avoid antagonist synergies), information on how to make exercises progressively more difficult, and data showing the efficacy of the whole programme. This study presents a complete PFMT programme, with full details and outcomes. A scheme of five progressive exercises was built, each with precise characteristics and times. Totally 131 patients with stress UI after radical retropubic prostatectomy were enrolled and followed a written scheme of PFMT with the five exercises. Leakages were quantified using the 24‐h pad test. Rehabilitation ended when patients had leakages less than 10 g/d. Nine patients could not achieve results and decided to exit the programme after a median of five sessions (InterQuartile Range, IQR = [4;7]). Out of the 122 patients, 90 patients who followed the full programme achieved the rehabilitation (70.3%); they had median leakages of 150 g, IQR = [90;300]. Those who did not reach the result had higher leakages [540 g/d, IQR = (300;840)] but obtained clinically significant reduction and reached a median of 90 g/d, IQR = [90;157] after comparable rehabilitation times (median of 6 or 7 sessions, corresponding to 8 or 10 weeks, for rehabilitated and non‐rehabilitated patients, respectively). Future studies will investigate the long‐term results of this programme. [ABSTRACT FROM AUTHOR]

Radiologists, oncologists, urologists and clinical nurse specialists met to evaluate how patients with high-risk localised or locally advanced prostate cancer might be better diagnosed and managed. In the first article in this series, the authors reviewed diagnosis and hormonal and radiotherapy.1 In this second paper, they evaluate findings from the meeting relating to the surgical management of the disease and how this might be optimised. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to assess the use of magnetic resonance guided adaptive radiotherapy (MRgART) in the post‐prostatectomy setting; comparing dose accumulation for our initial seven patients treated with fully adaptive workflow on the Unity MR‐Linac (MRL) and with non‐adaptive plans generated offline. Additionally, we analyzed toxicity in patients receiving treatment. Methods: Seven patients were treated with MRgART. The prescription was 70–72 Gy in 35–36 fractions. Patients were treated with an adapt to shape (ATS) technique. For each clinically delivered plan, a non‐adaptive plan based upon the reference plan was generated and compared to the associated clinically delivered plan. A total of 468 plans were analyzed. Concordance Index of target and Organs at Risk (OARs) for each fraction with reference contours was analyzed. Acute toxicity was then assessed at six‐months following completion of treatment with Common Terminology for Adverse Events (CTCAE) Toxicity Criteria. Results: A total of 246 fractions were clinically delivered to seven patients; 234 fractions were delivered via MRgART and 12 fractions delivered via a traditional linear accelerator due to machine issues. Pre‐treatment reference plans met CTV and OAR criteria. PTV coverage satisfaction was higher in the clinically delivered adaptive plans than non‐adaptive comparison plans; 42.93% versus 7.27% respectively. Six‐month CTCAE genitourinary and gastrointestinal toxicity was absent in most patients, and mild‐to‐moderate in a minority of patients (Grade 1 GU toxicity in one patient and Grade 2 GI toxicity in one patient). Conclusions: Daily MRgART treatment consistently met planning criteria. Target volume variability in prostate bed treatment can be mitigated by using MRgART and deliver satisfactory coverage of CTV whilst minimizing dose to adjacent OARs and reducing toxicity [ABSTRACT FROM AUTHOR]

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

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

Study Type - Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Research on the subject has shown that robotic surgery is more costly than both laparoscopic and open approaches due to the initial cost of purchase, annual maintenance and disposable instruments. However, both robotic and laparoscopic approaches have reduced blood loss and hospital stay and robotic procedures have better short term post-operative outcomes such as continence and sexual function. Some studies indicate that the robotic approach may have a shorter learning curve. However, factors such as reduced learning curve, shorter hospital stay and reduced length of surgery are currently unable to compensate for the excess costs of robotic surgery. This review concludes that robotic surgery should be targeted for cost efficiency in order to fully reap the benefits of this advanced technology. The excess cost of robotic surgery may be compensated by improved training of surgeons and therefore a shorter learning curve; and minimising costs of initial purchase and maintenance. The review finds that only a few studies gave an itemised breakdown of costs for each procedure, making accurate comparison of costs difficult. Furthermore, there is a lack of long term follow up of clinical outcomes, making it difficult to accurately assess long term post-operative outcomes. A breakdown of costs and studies of long term outcomes are needed to accurately assess the effectiveness of robotic surgery in urology. OBJECTIVES Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery., These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes., METHODS A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study., RESULTS Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1-1.76 days and 1-5.5 days, respectively) and blood loss (range 482-780 mL and 227-234 mL, respectively) when compared with the open approach (range 2-8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000-$39 215) than both laparoscopic (range US $740-$29 771) and open radical prostatectomy (range US $1870-$31 518)., This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1-1.5 days) and length of surgery (range 102-360 min) are unable to compensate for the excess costs., Robotic surgery may require a smaller learning curve (20-40 cases) although the evidence is inconclusive., CONCLUSIONS Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve., Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs., Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery. [ABSTRACT FROM AUTHOR]

Intraoperative electron beam radiotherapy (IOERT) for prostate cancer (PC) is a radiotherapeutic technique, giving high doses of radiation during radical prostatectomy (RP). This paper presents the published treatment approaches for intraoperative radiotherapy analyzing functional outcome, morbidity, and oncological outcome in patients with clinical intermediate-high-risk prostate cancer. A systematic review of the literature was performed, searching PubMed andWeb of Science. A "free text" protocol using the term intraoperative radiotherapy and prostate cancer was applied. Ten records were retrieved and analyzed including more than 150 prostate cancer patients treated with IOERT. IOERT represents a feasible technique with acceptable surgical time and minimal toxicity. A greater number of cases and longer follow-up time are needed in order to assess the long-term side effects and oncological outcome. [ABSTRACT FROM AUTHOR]

Objective. A number of evidence-based guidelines for diagnosis and management of prostate cancer have been published. The aim of this study is to evaluate the adherence of Italian urologists to the guidelines concerning the preoperative imaging staging of prostate cancer. Methods. In October 2007 a multicentric observational perspective study called Multicentric Italian Report on Radical prostatectomy Outcome and Research (MIRROR) was started in 135 Italian urology centers. Recruitment was closed in December 2008 and 2,408 cases were collected. In this paper we have taken into consideration all examinations carried out for preoperative imaging staging, evaluating compliance with the recommendations in the American Urological Association (AUA) and European Association of Urology (EAU) guidelines. Results. Five hundred sixty-seven (53.34%) patients were not managed according to the EAU guidelines concerning T-staging, 545 (51.27%) concerning N-staging and 757 (71.21%) concerning Mstaging. According to AUA guidelines, we also analyzed patients with a Gleason grade of biopsy specimens of 7: 238 (57.35%) of these patients had undergone testing for T staging, 244 (57.35%) for N-staging and 322 (77.60%) for M-staging. Conclusions. The compliance of Italian urologists with the guidelines is low, leading to an inappropriate increase in cost of care and unnecessary anxiety for the patients. [ABSTRACT FROM AUTHOR]

Severe persistent stress incontinence following radical prostatectomy for prostate cancer treatment, although not very common, remains the most annoying complication affecting patient's quality of life, despite good surgical oncological results. When severe incontinence persists after the first postoperative year and conservative treatment has been failed, surgical treatment has to be considered. In these cases it is generally accepted that artificial urinary sphincter is the gold standard treatment. AUS 800 by American Medical Systems has been successfully used for more than 35 years. Recently three more sphincter devices, the Flow- Secure, the Periurethral Constrictor, and the ZSI 375, have been developed and presented in the market. A novel type of artificial urinary sphincter, the TapeMechanical Occlusive Device, has been inserted in live canines as well as in human cadavers. These new sphincter devices are discussed in this paper focusing on safety and clinical results. [ABSTRACT FROM AUTHOR]

Quality of life has become increasingly more important for men diagnosed with prostate cancer. In light of this and the recognized risks of androgen deprivation therapy (ADT), the guidelines and use of ADT have changed significantly over the last few years. This paper reviews the current recommendations and the future perspectives regarding ADT. The benefits of ADT are evident neoadjuvantly and adjuvantly in patients treated with external beam radiation therapy for intermediate- and high-risk disease, in patients who have undergone prostatectomy with lymph node involvement, in high-risk patients after definitive therapy, and in patients who have developed progression or metastasis. Finally, this paper reviews the risks and benefits of each of these scenarios and the risks of androgen deprivation in general, and it delineates the areas where ADT was previously recommended, but where evidence is lacking for its additional benefit. [ABSTRACT FROM AUTHOR]

Erectile dysfunction and urinary incontinence secondary to sphincter dysfunction are common conditions affecting many men worldwide with a negative effect on quality of life. They are encountered in a number of etiologies most commonly following radical prostatectomy in which they coexist in the same patient. Implantations of an artificial urinary sphincter and inflatable penile prosthesis have proven to be effective in the treatment of both conditions should conservative and minimally invasive measures fail. The recent literature has shown that dual implantation of these devices is feasible and safe with a durable clinical outcome. Once indicated, this can be done in a synchronous or nonsynchronous manner; however, the emerging of the single transverse scrotal incision as well as advancement in the prostheses has made synchronous dual implantation more favourable and appealing option. It provides time and cost savings with an evidence of high patient satisfaction. Synchronous dual implantation should be offered initially when indicated. This paper discusses the surgical techniques of artificial urinary sphincter and inflatable penile prosthesis dual implantation in the management of concurrent moderate-to-severe urinary incontinence and medically refractive erectile dysfunction, in addition to highlighting the existing literature pertaining to this approach. [ABSTRACT FROM AUTHOR]

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

Low-dose rate brachytherapy has become a mainstream treatment option for men diagnosed with prostate cancer because of excellent long-term treatment outcomes in low-, intermediate-, and high-risk patients. To a great extend due to patient lead advocacy for minimally invasive treatment options, high-quality prostate implants have become widely available in the US, Europe, and Japan. High-dose-rate (HDR) afterloading brachytherapy in the management of localised prostate cancer has practical, physical, and biological advantages over low-dose-rate seed brachytherapy. There are no free live sources used, no risk of source loss, and since the implant is a temporary procedure following discharge no issues with regard to radioprotection use of existing facilities exist. Patients with localized prostate cancer may benefit from high-dose-rate brachytherapy, which may be used alone in certain circumstances or in combination with external-beam radiotherapy in other settings. The purpose of this paper is to present the essentials of brachytherapies techniques along with the most important studies that support their effectiveness in the treatment of prostate cancer. [ABSTRACT FROM AUTHOR]

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

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

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

It has been suggested that prostate cancer spread has predictable patterns, with prostate cancers known to affect the prostatic contours. However, few systematic investigations have documented the associated contour alterations, especially at a clinically localized stage. The purpose of the present paper was to objectively evaluate prostatic contour alterations based on left–right asymmetry, and analyze the histopathological features and prognostic impact. One hundred and sixty-two asymmetrical contours with left–right asymmetry in the length ≥10%, and 278 cancer foci were observed in 114 radical prostatectomy specimens. Of the asymmetrical contours, 55 (34%) were caused by cancer, and of the cancer foci, 55 (20%) generated asymmetrical contours. Cancer-associated asymmetries showed significant correlations with aggressive behaviors such as cancer volume, Gleason score, positive surgical margin, and extraprostatic extension, although these were not significantly associated with unfavorable prognosis. The authors present basic data relating to altered prostatic contours, such as spatial distribution and causative pathological conditions. Clinicopathological characteristics concerning cancer-associated contour alterations, are also presented in detail. [ABSTRACT FROM AUTHOR]

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

Aim. This paper reports a study to assess the usability and use of different pain assessment tools and to compare patients’ and nurses’ pain assessments in the recovery room after prostatectomy. Background. Pain assessment is the first step towards providing adequate pain relief but poses problems because of the subjective nature of the pain experience and the lack of quantifiable measurements. Pain tools have been tested in several clinical settings, but not in the recovery room. Methods. Data were collected in the recovery room from 45 consecutive patients who had undergone prostatectomy by asking them to evaluate their pain intensity using visual analogue scale, numeric rating scale and verbal expressions. One of two research nurses measured patients’ pain at regular intervals and at the same time as the patients. Physiological parameters were also evaluated. Data were analysed as frequencies and percentages. Sum variables were formed and results were analysed using Spearman's rank correlation, Pearson's correlation and with multiple regression analysis. Results. Patients varied in their ability to assess the intensity of their pain using different tools, but assessments were correlated with each other and with nurses’ estimations. Nurses and patients obtained similar assessments, but nurses both underestimated and overestimated patients’ pain. Patients’ verbal assessments varied widely. Patients’ and nurses’ pain assessments showed no association with patients’ pulse or mean arterial blood pressure. Conclusions. According to our results, it is not totally clear whether pain tools are usable in the recovery room. This issue calls for further research. [ABSTRACT FROM AUTHOR]

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

Prostate cancer is one of the most common malignancies worldwide and the fifth leading cause of cancer deaths in men. With the rapidly increasing surgical rate of minimally invasive radical prostatectomy, there is still controversy about how to use a urinary catheter post‐operatively. Thus, we attempted to compare the post‐operative wound‐related outcomes through a meta‐analysis of urethral catheterisation (UC) versus suprapubic catheterisation (SPC) after minimally invasive radical prostatectomy. As of August 2023, the authors conducted systematic searches in databases such as PubMed, Embase, Web of Science and the Cochrane Library. The authors reviewed the relevant literature separately to determine comparisons between SPC and UC treatment after radical prostatectomy. A total of 395 subjects were enrolled in the five trials, met the eligibility criteria and were included in the meta‐analysis. Data collection and analysis revealed significant differences in catheter bother to patients for surgical trauma (MD, 0.98; 95% CI, 0.48, 1.48 p = 0.0001), with SPC causing less catheter bother to patients post‐operatively; post‐operative catheter‐related problems (OR, 3.3; 95% CI, 0.03, 326.1 p = 0.61), the POD1 of the post‐operative period (MD, − 0.09; 95% CI, −0.75, 0.94 p = 0.83) and the POD3 of the post‐operative period (MD, −0.49; 95% CI, −0.99, 0.01 p = 0.06); there was no statistically significant difference in wound pain. Compared with UC, SPC patients had less post‐operative catheter distress. Thus, SPC is more beneficial in reducing post‐operative wound discomfort in patients. The validity of the results remains to be tested in more and better studies. [ABSTRACT FROM AUTHOR]

B (Osaka, Japan) b analyzed the association between molecular subtypes and PD-L1 expression in upper tract urothelial cancer, and showed that it might have a different pattern from bladder cancer. It is known that upper tract urothelial cancer and bladder cancer have different biological characteristics, although both are the same histological type. This nomogram might help general practitioners, pediatricians and the patient's family identify the patients who require prompt surgical intervention. [Extracted from the article]

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

How can nurses assess the self‐management of lower urinary tract symptoms (LUTS) in patients with cancer after radical prostatectomy (RP)? Patients with prostate cancer who have undergone RP experience multiple LUTS. This study aimed to develop a self‐management scale for LUTS in patients with cancer following RP (SMS‐LUTS‐RP), as well as to verify its reliability and validity. LUTS has physical, social, and psychological consequences for patients. As a result, patients are forced to self‐manage their LUTS and LUTS‐related issues. However, no indicators exist to assess self‐management of LUTS. A total of 246 individuals were surveyed. A 49‐item scale draft, whose content validity and face validity were confirmed, was used to develop a questionnaire for patients with LUTS after RP. The reliability and validity were determined using by item analysis, exploratory factor analysis, confirmatory factor analysis, and Cronbach's α coefficient. The exploratory factor analysis produced the following 18 items on five extracted factors: 'monitoring of urinary status,' 'coping with daily life difficulties due to LUTS,' 'collaboration with medical professionals,' 'continued training to improve LUTS,' and 'living with LUTS.' The goodness‐of‐fit‐index (GFI) for confirmatory factor analysis was 0.876, and the root mean square error of approximation was 0.075. Cronbach's α coefficient was 0.754–0.820. SMS‐LUTS‐RP has desirable psychometric properties and can assess the cognitive and behavioural aspects of self‐management of LUTS in patients with cancer who have undergone a RP. This scale can be used to provide individualized self‐management support according to living conditions. [ABSTRACT FROM AUTHOR]

We present here a case of invasive bladder carcinoma in a 51-year-old man with Behçet's disease (BD). A radical cystoprostatectomy was performed and postoperative chemotherapy was administered to treat lymph node metastasis. However, the patient died 6 months after the operation. Malignancies associated with BD are very uncommon. The incidence, diagnosis and management of our case is discussed in the present paper. [ABSTRACT FROM AUTHOR]