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Objective: This study aimed to investigate the association between Photodynamic Diagnosis (PDD) with hexaminolevulinate (HAL) and the rate of complete resection and disease persistence at first follow-up cystoscopy for non-muscle-invasive bladder cancer (NMIBC) in UK real-world practice. Methods: Audit data were pooled from six UK centres where HAL PDD was used in patients with a new NMIBC diagnosis undergoing transurethral resection of bladder tumours (TURBT) since 2008. Patients received adjunctive intra-vesical therapy and surveillance in line with European and UK guidelines, including early re-resection in high-grade NMIBC. Results: PDD-assisted TURBT was done in 837 patients with new NMIBC. The detrusor muscle was present in 69.4% of cases. At early re-TURBT in 207 high-risk patients, 13.0% had residual disease. Multifocal disease was the most significant factor in increasing the rate of residual disease (odds ratio excluding cases of CIS=4.1; 95% confidence interval 1.5–11.3). The recurrence rate at first follow-up cystoscopy (RRFFC) was 10.6% (8.9% in patients with complete initial TURBT). In the historical cohort undergoing good-quality white-light TURBT, RRFFC was 31%; 40.5% of high-risk patients had residual disease at early re-TURBT. Conclusion: HAL PDD may increase the rates of complete resection, reducing the risk of early recurrence and the need for routine re-resection in high-grade NMIBC. Level of evidence: 2b.

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Apart from bladder tumour multiplicity, size, stage, grade and presence of cis, early recurrence following white light TURBT for new bladder tumours is also determined by surgeon experience, completeness of resection and presence or absence of detrusor muscle in the specimen. This study aims to validate surgeon experience and detrusor muscle as independent predictors of early recurrence following apparently complete white light TURBT in new bladder tumours. OBJECTIVE • To validate in patients undergoing first transurethral resection of bladder tumour (TURBT) for non-muscle-invasive bladder cancer (NMIBC), the presence/absence of detrusor muscle (DM) in the specimen and surgeon experience as independent predictors of the quality of TURBT. PATIENTS AND METHODS • Patients with new NMIBC, who had undergone complete first resections were recruited from a prospectively maintained cohort from the 1980s at the Western General Hospital, Edinburgh, UK and a contemporary cohort from the Aberdeen Royal Infirmary, UK. • Tumour size, multiplicity, surgeon category, presence or absence of DM in the specimen, grade, stage, findings at first check cystoscopy and early re-TURBT were evaluated. • Surgeons were stratified into a senior group (consultant and trainees in year five or six) and a junior group (trainees below year five). • Early recurrence, or recurrence rate at the first follow up cystoscopy (RRFFC), was used to measure quality and was defined as finding pathologically confirmed tumour at early re-TURBT or the first check cystoscopy. RESULTS • From a total of 566 patients evaluated from both cohorts, 473 NMIBC specimens were suitable for analysis. • Logistic regression multivariate analysis revealed that the absence of DM was associated with a higher RRFFC (odds ratio [OR]= 3.6, 95% CI = 1.7–7.5, P < 0.001). • Senior surgeons were more likely to resect DM (OR = 4.9, 95% CI = 2.3–10.7, P < 0.001) • Senior surgeons were independently associated with a lower RRFFC (OR = 5.3, 95% CI = 2.1–12.9, P < 0.001). CONCLUSIONS • Detrusor muscle status at the first, apparently complete, TURBT and surgeon's experience independently predict the quality of TURBT. • Documented complete resection by experienced surgeons with DM presence (good quality white-light TURBT) should be considered a benchmark for white-light TURBT in NMIBC.

Background An European Organisation for Research and Treatment of Cancer analysis of multicentre trials found significant interinstitutional variability in recurrence rates at first follow-up cystoscopy (RR-FFC) and attributed this to variable transurethral resection of bladder tumour (TURBT) quality. Objective To determine whether resection of detrusor muscle (DM) in the first, apparently complete TURBT is a surrogate marker of quality and whether the presence of DM is dependent on a surgeon's experience. Design, setting, and participants Over a 2-yr period, patients with new bladder tumours that were judged to have been completely resected were recruited from our prospectively maintained bladder tumour database. Strict exclusion criteria were applied. Measurements Prospectively recorded tumour size, tumour multiplicity, surgeon category, DM status, grade and stage of tumour, and findings at first follow-up cystoscopy (at 3 mo) and at early re-TURBT were evaluated. Surgeons were stratified into seniors (consultants and year 5 or year 6 trainees) and juniors (trainees lower than year 5). Early recurrence (for calculating RR-FFC) was defined as pathologically confirmed tumour on early re-TURBT or recurrence at the first follow-up cystoscopy. Logistic regression multivariate analyses were carried out to determine associations between variables. Results and limitations In a total of 356 patients, DM was present in 241 patients (67.7%). Multivariate analyses revealed that large tumours, high-grade tumours, and surgery by senior surgeons was independently associated with the presence of DM in the resected specimens. The RR-FFCs when DM was absent and present were 44.4% and 21.7%, respectively (odds ratio: 2.9; 95% confidence interval: 1.6–5.4; p =0.0002). The absence of DM and resection by less experienced surgeons independently predicted a higher RR-FFC. This association was also seen in small and low-grade tumours. The number of patients in this study appears modest, and further validation may be required. Conclusions DM absence or presence in the first, apparently complete TURBT specimen appears to be a surrogate marker of resection quality by independently predicting the RR-FFC, which is also dependent on surgeon experience.

Bladder outflow obstruction is a very common age-related clinical entity due to a variety of benign and malignant diseases of the prostate. Surgical treatment under general or regional anesthesia is not suitable for high-risk elderly patients who seek minimally invasive management. Unfortunately, for patients who are not fit for transurethral and/or laser prostatectomy, few treatment options remain, other than long-term catheterization and insertion (under local anesthesia) of a prostatic stent. In this review, we present developments in the use of prostatic stents.

Objectives: Our purpose was to review current practice regarding the use of prostate biopsies in men older than 75 years with raised PSA by presenting the results of a retrospective audit and to identify these older men who really benefit from prostate biopsies. Methods: A high-volume tertiary center’s prospectively maintained prostate biopsy database of contemporary biopsies was reviewed. Men were stratified by age and PSA. Logistic regression analysis, Mantel-Haenszel and Fisher’s exact tests were used for statistical analysis. Results: Overall, 1,593 men underwent prostate biopsies between April 2004 and August 2006. Of these, 293 patients (18.4%) with a mean age of 82.62 years and mean PSA of 30.37 ng/ml were eligible for the study with an overall incidence of prostate cancer of 73.7%. Elderly men with PSA >20 ng/ml had a prostate cancer detection rate of 91%. They were more likely to have-high grade disease (OR = 5.4, 95% CI = 2.8–10.8, p < 0.0001) and receive hormone deprivation therapy (RR = 3.0, 95% CI = 2.1–4.3, p < 0.0001). Elderly men with PSA Conclusions: Given the high probability of detecting prostate cancer and receiving conservative treatment, prostate biopsies can be omitted in men >75 years with PSA >20 ng/ml. However, they are still useful in fit men >75 and