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The learning curve for robotic-assisted radical prostatectomy (RARP) is estimated to be about 50–200 cases. This study will evaluate the benefit of a mentorship programme after completing a mini-fellowship in RARP by an experienced surgeon who previously trained in open and laparoscopic surgery. Our study was a retrospective comparative analysis of RARP performed by a single consultant urologist. A retrospective chart review of the first 120 cases was performed. The 120 patients were divided into three groups of 40 cases. For the first 40 cases, an appropriately qualified mentor was present. The peri-operative and oncological outcomes were compared between the three groups. Operative times significantly decreased with experience (250 min vs 234 min vs 225 min, p

Objective: The purpose of this article is to present our minimally-invasive techniques for upper tract urothelial carcinoma and review the perioperative and early oncological outcomes at our centre. Materials and methods: A retrospective review of all patients undergoing minimally-invasive surgery for upper tract urothelial carcinoma over a 3-year period following institutional approval was performed. Perioperative and early oncological outcomes were assessed. Results: Twenty-three cases of minimally-invasive single-stage nephroureterectomy were performed with a mean patient age of 69.45 years. Twelve (52%) of these cases were for high-grade disease and six (27%) had received neo-adjuvant chemotherapy. There were no intraoperative complications, no positive surgical margins and four (17.4%) of patients had a post-operative complication. Mean length of stay was 5.5 days and there was one readmission within 30 days of surgery. Seven patients (30%) experienced either local or distant recurrences with a median time to recurrence of 6 months. Recurrence free survival was 69.6%. Two patients died during the follow-up period. Conclusion: Our minimally-invasive techniques provides a safe and reproducible approach for upper tract urothelial carcinoma. Our perioperative outcomes and oncological are comparable to similar studies, but more long-term follow-up and larger patient numbers are required to validate oncological efficacy. Level of evidence: 4.

Background The risk of injury to the ureter during an abdominal hysterectomy is estimated at 1.3% [1] . This injury often occurs following ligation of the uterine vessels as the ureter crosses under the artery. Objective To illustrate a minimally-invasive approach in the surgical management of a distal ureteric injury. Method A 45 year old female was reviewed in an outpatient setting with a left nephrostomy insitu following an intraoperative injury to her left distal ureter during a hysterectomy for a large fibroid. An initial attempted endoscopic realignment procedure was unsuccessful. Operative method The ureter was mobilised proximal to healthy tissue with preservation of the adventitia. The bladder was mobilised and a psoas hitch performed to ensure a tension free anastomosis. The ureter was then spatulated and anastomosed into the bladder over a JJ stent. Results The patient had an uneventful post-operative course and was discharged home on day 4 with the JJ stent and urinary catheter insitu. At post-operative day 14, the patient returned for a urinary catheter removal, cystoscopy and JJ stent removal, the ureteric reimplantation was found to be successful. Conclusion A robotic assisted technique is a safe and effective approach for distal ureteric reimplantation.

‘Prophylactic’ ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk–benefit equation of this practice, and we aimed to assess the evidence base. A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms ‘ureteric/ureteral/JJ/Double J stent’ or ‘ureteric/ureteral catheter’ and ‘colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury’. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Advances in minimally invasive therapies and novel targeted chemotherapeutics have provided a breadth of options for the management of renal masses. Management of renal angiomyolipoma has not been reviewed in a comprehensive fashion in more than a decade. We provide an updated review of the current diagnosis and management strategies for renal angiomyolipoma.We conducted a PubMed(®) search of all available literature for renal or kidney angiomyolipoma. Further sources were identified in the reference lists of identified articles. We specifically reviewed case series of partial nephrectomy, selective arterial embolization and ablative therapies as well as trials of mTOR inhibitors for angiomyolipoma from 1999 to 2014.Renal angiomyolipoma is an uncommon benign renal tumor. Although associated with tuberous sclerosis complex, these tumors occur sporadically. Risk of life threatening hemorrhage is the main clinical concern. Due to the fat content, angiomyolipomas are generally readily identifiable on computerized tomography and magnetic resonance imaging. However, fat poor angiomyolipoma can present a diagnostic challenge. Novel research suggests that various strategies using magnetic resonance imaging, including chemical shift magnetic resonance imaging, have the potential to differentiate fat poor angiomyolipoma from renal cell carcinoma. Active surveillance is the accepted management for small asymptomatic masses. Generally, symptomatic masses and masses greater than 4 cm should be treated. However, other relative indications may apply. Options for treatment have traditionally included radical and partial nephrectomy, selective arterial embolization and ablative therapies, including cryoablation and radio frequency ablation, all of which we review and update. We also review recent advances in the medical treatment of patients with tuberous sclerosis complex associated angiomyolipomas with mTOR inhibitors. Specifically trials of everolimus for patients with tuberous sclerosis complex suggest that this agent may be safe and effective in treating angiomyolipoma tumor burden. A schema for the suggested management of renal angiomyolipoma is provided.Appropriately selected cases of renal angiomyolipoma can be managed by active surveillance. For those patients requiring treatment nephron sparing approaches, including partial nephrectomy and selective arterial embolization, are preferred options. For those with tuberous sclerosis complex mTOR inhibitors may represent a viable approach to control tumor burden while conserving renal parenchyma.

Ureteric stents are frequently placed following endo-urological procedures. These stents cause significant morbidity for patients. Standard ureteric stents are removed by flexible cystoscopy. This procedure can be unpleasant for patients and requires additional resources. A newly designed magnetic stent allows removal in an outpatient setting. The aim of our study is to compare the magnetic stent and standard ureteric stents with regard to morbidity, pain on stent removal and cost-effectiveness. This study was carried out across two sites between September 2016 and July 2017. In site A, a magnetic stent (Urotech, Black-Star®) is removed by magnetic retrieval device. Fifty consecutive patients completed the validated Ureteric Stent Symptom Questionnaire (USSQ) and visual analogue scale (VAS) at the time of stent removal. On site B, a soft polyurethane stent (Cook Universa) was removed by flexible cystoscopy. Fifty patients were identified retrospectively and completed questionnaires by post. Cost analysis was also performed. One hundred questionnaires were included for analysis. No significant difference in stent morbidity as assessed by the USSQ was shown between both groups. Median duration of stenting was significantly shorter in the magnetic stent group (5.5 versus 21.5 days, p

Previous studies analyzing the relationship between Body Mass Index (BMI) and complications after partial nephrectomy have been underpowered. We use a national surgical database to explore the association of BMI with postoperative outcomes for Open Partial Nephrectomy (OPN) and Minimally Invasive Partial Nephrectomy (MIPN).Years 2005-2012 of the National Surgical Quality Improvement Program (NSQIP) were queried for OPN and MIPN. Postoperative complications were organized according to Clavien Grades and compared across normal weight (BMI kg/m(2)=18.5-25.0), overweight (BMI=25.0-30.0), and obese (BMI≥30.0) patients using standard descriptive statistics and multivariate regression modeling.Of 1667 OPNs and 2018 MIPNs, 46.2% of patients were obese. Operative time was 16.91 minutes longer on average for obese patients (p0.001). The overall complication rate after OPN was 17.9%, 17.2%, and 17.9% (p=0.945) for normal weight, overweight, and obese patients, respectively; while the overall complication rate after MIPN was 6.9%, 6.3%, and 8.7% (p=0.147). Multivariate regression analysis demonstrated that overweight and obese patients were not at increased risk for any complication grade after OPN and MIPN compared to normal weight patients. When comparing procedures, MIPN had a lower complication rate compared to OPN for obese (8.7% vs 17.9%, p0.001) and morbidly obese patients (9.2% vs 22.2%, p=0.001).Although surgery in obese patients is longer compared to normal weight patients, it does not appear to increase the likelihood of 30-day postoperative complications for OPN or MIPN. However, obese patients undergoing MIPN had lower complication rates than those undergoing OPN.

Genetic studies have identified single nucleotide polymorphisms (SNPs) associated with the risk of prostate cancer (PC). It remains unclear whether such genetic variants are associated with disease aggressiveness. The NCI-SPORE Genetics Working Group retrospectively collected clinicopathologic information and genotype data for 36 SNPs which at the time had been validated to be associated with PC risk from 25,674 cases with PC. Cases were grouped according to race, Gleason score (Gleason ≤6, 7, ≥8) and aggressiveness (non-aggressive, intermediate, and aggressive disease). Statistical analyses were used to compare the frequency of the SNPs between different disease cohorts. After adjusting for multiple testing, only PC-risk SNP rs2735839 (G) was significantly and inversely associated with aggressive (OR=0.77; 95% CI 0.69–0.87) and high-grade disease (OR=0.77; 95% CI 0.68–0.86) in European men. Similar associations with aggressive (OR=0.72; 95% CI 0.58–0.89) and high-grade disease (OR=0.69; 95% CI 0.54–0.87) were documented in African-American subjects. The G allele of rs2735839 was associated with disease aggressiveness even at low PSA levels (

To evaluate contemporary national trends and outcomes of open pyeloplasty (OP) vs minimally invasive pyeloplasty (MIP) in the treatment of ureteropelvic junction obstruction using the National Surgical Quality Improvement Program database.Patients treated by OP or MIP between 2006 and 2011 were identified by The International Classification of Diseases, Ninth Revision, Clinical Modification codes corresponding to pyeloplasty as their primary operative procedure. Perioperative variables were analyzed using the chi-square and the Student t test. Multiple logistic regressions were used to identify morbidities and readmission risk factors.Three hundred fifty-five patients were identified. Of them, 20.2% of cases were OP and 79.8% were MIP. There was a significant increase in MIP from 33% in 2006 to 83% in 2011 (P.001). A total of 11.7% of patients in the MIP group underwent outpatient surgery (P = .002). Patients treated at a teaching hospital were over 3 times more likely to undergo MIP (odds ratio = 3.17; P = .001). There was significantly longer hospitalization in OP vs MIP (3.9 vs. 2.2 days; P = .001). OP was associated with significantly increased risk of reoperation or postoperative morbidity compared with MIP (11.1% vs. 4.2%; P = .02). Multivariate analysis confirmed a higher rate of overall morbidity in the OP cohort (P = .03). Male patients had significantly higher postoperative morbidity or reoperation rates (odds ratio = 4.38; P = .002). There was no significant difference in operative time between groups (P = .2).Within the American College of Surgeons National Surgical Quality Improvement Program hospitals, MIP is associated with decreased reoperation and postoperative morbidity compared with OP.

Many American hospitals will soon face readmission penalties deducted from Medicare reimbursements, which will place further scrutiny on techniques that may offer reduced postoperative morbidity. We aimed to perform the first multi-institutional study using the National Surgical Quality Improvement Program (NSQIP) database, to compare predictors of readmission within cohorts of open radical retropubic prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) in a contemporary nationwide series of radical prostatectomy.All patients who underwent radical prostatectomy in 2011 were identified in the NSQIP database using procedural codes. As no patients in the analysis underwent LRP, patients were grouped as RRP or RALRP for analysis. Perioperative variables were analyzed using chi-squared and Student's t-tests as appropriate. Multiple logistic regression was used to identify readmission risk factors.Of 5471 patient cases analyzed, 4374 (79.9%) and 1097 (20.1%) underwent RALRP and RRP, respectively. RRP and RALRP cohorts experienced different readmission rates (5.47% vs 3.48%, respectively; p=0.002). In addition, RRP experienced a higher rate of overall complications than RALRP (23.25% vs 5.62%, respectively; p0.001), but not higher rates of reoperation (1.09% vs 0.96%, respectively; p=0.689). Overall predictors of readmission included operative time, dyspnea, and RRP or RALRP procedure type. Current smoking and patient age were predictive of readmission for RRP only, while dyspnea was predictive of readmission following RALRP only.This is the first multi-institutional retrospective study that examines readmission rates and procedural intracohort predictors of readmission for RRP in the contemporary United States. We report a significant difference in postoperative complication and readmission rates in RRP compared with RALRP. Further prospective analysis is warranted.

Objective There are increasing reports of infectious complications following prostate biopsy due to fluoroquinolone resistance. To determine infectious complications at catheter removal following radical prostatectomy (RP), another setting in daily urological practice where fluoroquinolone prophylaxis is frequently used. Materials and methods We prospectively examined urine culture results collected from 334 RP patients immediately prior to catheter removal. Patients received prophylactic antibiotics 1 day before, the day of, and for 5 days after catheter removal. Culture results were reviewed for bacterial species and antimicrobial susceptibilities. Patients with positive urine cultures resistant to the prophylactic antibiotic were switched to culture-specific antibiotic therapy and underwent follow-up culture. The frequency of urinary tract infection (UTI), complications, additional antibiotic therapy, and repeat urine cultures was determined within 60 days. Results Of the 334 patients identified, 203 (61%) had cultures with no bacterial growth, and 48 (14%) had colony counts of Candida albicans and received no further antibiotics. The remaining 83 (25%) had positive culture results, of which 7% were resistant to ciprofloxacin. Twenty-four bacterial species were identified, with Pseudomonas aeruginosa (5%) Escherichia coli (4%), and Staphylococcus epidermidis (3%) being the most frequent. Only two (0.6%) men developed clinical symptoms consistent with UTI (i.e., suprapubic pain, fever) prior to catheter removal, and no serious complications occurred. Conclusions A substantial proportion of RP patients have positive urine cultures at the time of catheter removal, despite the administration of prophylactic fluoroquinolone antibiotics. Potentially virulent organisms are commonly cultured, and ciprofloxacin resistance is frequent. However, outcomes are favorable when culture-specific oral antibiotic therapy is initiated.

Objectives: To examine temporal trends in clinico-pathological outcomes following radical prostatectomy (RP) in Ireland over time, and perform matched comparison of between Ireland and the USA based upon initiation of prostate-specific antigen (PSA) screening. Methods: Between 2000–2010, 651 RPs were carried out at a single institution in Ireland. Clinic-pathologic tumor features were compared to 1302 men treated in the USA from the same time interval (matching on year of diagnosis, 1:2 ratio). As historical comparison, we included a separate group of 150 USA men who underwent RP during the early PSA era (1990–1992). Results: We observed a downward migration in biopsy tumor burden ( p=0.002), RP tumor volume ( pConclusions: During the past decade of increasing PSA utilization in Ireland, we found evidence of pathological stage migration. In comparison to a USA population, Irish men have worse pathological characteristics, however, in comparison to the early USA PSA era, Irish men are more likely to have organ-confined disease.

Purpose: Recent studies have identified genetic variants associated with increased serum prostate specific antigen concentrations and prostate cancer risk, raising the possibility of diagnostic bias. By correcting for the effects of these variants on prostate specific antigen, it may be possible to create a personalized prostate specific antigen cutoff to more accurately identify individuals for whom biopsy is recommended. Therefore, we determined how many men would continue to meet common biopsy criteria after genetic correction of their measured prostate specific antigen concentrations.Materials and Methods: The genotypes of 4 single nucleotide polymorphisms previously associated with serum prostate specific antigen levels (rs2736098, rs10788160, rs11067228 and rs17632542) were determined in 964 healthy Caucasian volunteers without prostate cancer. Genetic correction of prostate specific antigen was performed by dividing an individual's prostate specific antigen value by his combined genetic risk. Analy...

Recent evidence would suggest a low rate of metabolic assessment in stone formers, even in those deemed as high risk. We wished to assess the attitudes and practice patterns of metabolic work up in North American members of the Endourological Society as part of the management of stone-forming patients.A 12-question online multiple-choice questionnaire (using Survey Monkey(®)) was distributed to all members of the Endourological Society through e-mail. Descriptive analyses were performed.A total of 124 North American members of the Endourological Society responded (90% endourologists, 65% fellowship trained). Ninety-seven percent perform metabolic assessments without referring to a consultant. Eighty-three percent use a commercial analysis company and 17% request serum or urine parameters individually. Ninety-seven percent believe that 24-48-hour urine collection is a better way of assessing patients for metabolic abnormalities than a "basic analysis." Many respondents (37%) would be more likely to metabolically assess if results were easier to interpret, and 35% would like assistance/advice in the interpretation of results. At initial investigation of a first-time stone former, 87% of respondents use serum chemistry, 48% use 24-hour urine, 26% use 48-hour urine (two consecutive 24-hour urine collections), 54% send stone for analysis, and 7% do not investigate. On recurrent stone formers, 69% use serum chemistry, 73% use 24/48-hour urine, and 23% send stone for analysis. On routine follow-up, 36% check serum chemistry, 55% use 24-hour urine, 2% use 48-hour urine, and 29% do not metabolically evaluate. The majority agree that pharmacologic therapy plays a strong role in preventing recurrence (90%). After initiating pharmacologic therapy, 59% reassess using serum chemistry and 84% and 7% use 24/48-hour urine collection, respectively. Physicians re-evaluate patients after 1 month (7%), 1-2 months (10%), 2-4 months (44%), 4-6 months (30%), or after 6-12 months (7%).This snapshot assessment of Endourological Society members' practices in the metabolic investigation of stone-forming patients demonstrates wide testing variations. Many physicians expressed interest in assistance/advice in the interpretation of the metabolic assessment results.

Introduction and Objectives. Robotic partial nephrectomy with peritumoral radiofrequency ablation (RFA-RPN) is a novel clampless technique. We describe oncologic and functional outcomes in a prospective cohort. Methods. From May, 2007, to December, 2009, 49 consecutive patients with renal masses Results. In total, 49 tumors were treated in the RFA-RPN group and 36 tumors in the comparison group. Mean operative time was longer in the RFA-RPN group (370 min versus 293 min, p<0.001). There were no significant differences in mean EBL (231 cc versus 250 cc, p=0.42), transfusion rate (8.2% versus 11.1%, p=0.7), or hospital stay (3.9 versus 4.4 days, p=0.2). Two patients in the RFA-RPN (4.1%) and 1 (2.7%) patient in the comparison group had a positive surgical margin (p=0.75). 17 (34.7%) patients had a postoperative urine leak in the RFA-RPN group versus 2 (5.6%) patients in the comparison group (p=0.001). Mean follow-up was 54 months versus 68.4 months in the comparison group. There was no significant difference between the two groups regarding change in GFR (p=0.67). There were 3 recurrences (6.1%) in the RFA-RPN group and 0 recurrences in the RPN group (p=0.23). There were 3 deaths (6.1%) in the RFA-RPN group (one cancer specific) and 4 deaths (11.1%) in the RPN group (non-cancer specific) over the follow-up period (p=0.44). Conclusions. Our data suggests that this technique is associated with a similar degree of renal preservation but higher rates of postoperative urine leak and possibly higher rates of recurrence.

What's known on the subject? and What does the study add? There have been several studies that have suggested there may be a relationship between prostate biopsy and erectile function and LUTS. Previous studies have suggested a specific association between the type of local anaesthesia administered and/or the number of biopsies performed. Other studies have suggested an exacerbation of LUTS after prostate biopsy. The present study identifies a positive cancer diagnosis as a novel characteristic that may explain a relationship between biopsy and worsening erectile function. Objective To evaluate prospectively the characteristics, erectile function and lower urinary tract symptoms (LUTS) of men undergoing prostate needle biopsy (PNBx). Patients and Methods From 2008 to 2011, 134 men were prospectively administered the International Index of Erectile Function (IIEF), American Urological Association Symptom Index (AUA-SI), and quality-of-life (QoL) questionnaires before and after undergoing a single 12-core PNBx. Comparisons of IIEF and AUA-SI scores before and after PNBx, based upon baseline characteristics and prostate cancer (PCa) diagnosis, were performed. Univariable and multivariable logistic regression models were used to characterize predictors of change in IIEF scores. Results In the 85 men who fulfilled the inclusion criteria, there were no significant differences between the mean (sd) total pre-biopsy and the mean (sd) post-biopsy IIEF scores: 57.8 (12.9) vs 54.3 (17.2). Subgroup analysis showed that men who had biopsy-proven PCa had significantly greater changes in their post-biopsy IIEF scores compared with men without (−10.1 vs. 1.0; P < 0.001). After specific analyses of the IIEF domains in these groups we found significant decreases in every domain, including erectile function (P = 0.01). On multivariate analyses, only PCa diagnosis was associated with a significant change in IIEF (odds ratio 7.2; P = 0.003). There were no differences in AUA-SI or QoL scores in the overall population or in subgroups. Conclusions Cancer diagnosis appears to have an adverse effect on the erectile function of men undergoing PNBx but no effect on LUTS. This study highlights a potential negative psychological confounder that may influence erectile function before the treatment of PCa. Additional prospective trials evaluating these relationships are warranted.

Study Type – Prognosis (cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Men fail active surveillance for a variety of reasons; however, no single reliable biomarker has been found to date which will identify these men from the outset. We know that there are about 35 prostate cancer risk alleles which have been discovered to influence risk of prostate cancer, from large-scale genome-wide association studies. Some of these have been associated with aggressive prostate cancer. Nobody has examined the potential for these risk alleles to predict men who might fail active surveillance. This study adds to the growing evidence that single nucleotide polymorphisms may be able to identify men who have aggressive prostate cancers, and that this could be part of a risk algorithm used in active surveillance protocols. OBJECTIVE • To assess whether the carrier status of 35 risk alleles for prostate cancer (CaP) is associated with having unfavourable pathological features in the radical prostatectomy specimen in men with clinically low risk CaP who fulfil commonly accepted criteria as candidates for active surveillance. PATIENTS AND METHODS • We studied men of European ancestry with CaP who fulfilled the commonly accepted clinical criteria for active surveillance (T1c, prostate-specific antigen

Objective To design and construct a urinary bladder bioreactor for urologic tissue-engineering purposes and to compare the viability and proliferative activity of cell-seeded extracellular matrix scaffolds cultured in the bioreactor with conventional static growth conditions. Materials and Methods A urinary bladder bioreactor was designed and constructed to replicate physiologic bladder dynamics. The bioreactor mimicked the filling pressures of the human bladder by way of a cyclical low-delivery pressure regulator. In addition, cell growth was evaluated by culturing human urothelial cells (UCs) on porcine extracellular matrix scaffolds in the bioreactor and in static growth conditions for 5 consecutive days. The attachment, viability, and proliferative potential were assessed and compared with quantitative viability indicators and by fluorescent markers for intracellular esterase activity and plasma membrane integrity. Scaffold integrity was characterized with scanning electron microscopy and 4′,6-diamidino-2-phenylindole staining. Results No significant difference in cell viability was identified between both experimental groups after 3 days of culture (P = .06). By day 4, the number of viable UCs was significantly greater in the bioreactor compared with the number cultured under static conditions (P = .009). A significant difference in UC viability was also present after 5 days of culture between the bioreactor and static group (P = .006). Viability/cytotoxicity assays performed on day 5 also confirmed the viability of UCs in both experimental groups. Conclusion Significantly greater UC growth occurred on the extracellular matrix scaffolds cultured in the bioreactor compared with conventional static laboratory conditions after 3 days of culture. Our initial bioreactor prototype might be helpful for permitting additional advances in urinary bladder bioreactor technology.

Incidence of obesity and renal cell carcinoma (RCC) are increasing, and RCC remains a lethal disease if not identified at an early stage. There is an increasing body of evidence linking obesity to the risk of developing RCC.There is a wealth of epidemiological evidence supporting a higher risk of developing RCC in obese individuals, and in a dose-response manner. This is particularly pertinent in the development of the clear cell subtype (ccRCC), in which there appears to be a special interplay between ccRCC, obesity and von Hippel-Lindau (VHL) gene defects, driving the proangiogenic/proliferative pathway as a result of metabolites produced by adipose tissue, the epigenetic silencing of a tumour suppressor in close proximity to the VHL gene, hypoxia, obesity-related hypertension, lipid peroxidation and increased insulin-like growth factor-1.Obesity-related diseases, including cancers, are increasing. There are many complex biomolecular pathways interacting in obesity, especially in ccRCC in which there appears to be a specific interplay in VHL mutations.

Summary Introduction There are no published urological guidelines for the management of antithrombotic agents during the perioperative period. Aims To demonstrate variations in urological perioperative protocols for the antithrombotic agents aspirin, clopidogrel and warfarin. Materials and methods Consultant urologists from the BAUS registry completed an online questionnaire on perioperative management of antithrombotic agents in urological surgery. Urologists were requested to indicate whether they routinely discontinued aspirin, clopidogrel or warfarin during the perioperative period for 11 different urological procedures. Respondents that discontinued an antithrombotic agent were requested to indicate the number of days the agent was discontinued preoperatively and recommenced postoperatively. Results Of the 400 urologists surveyed, 210 (52.5%) responded. The percentage of respondents that continued each antithrombotic agent varied widely in each of the 11 procedures assessed (aspirin: range 48–82%; clopidogrel: 1–50%; warfarin: 2–40%). Respondents were most likely to continue an antithrombotic agent prior to diagnostic ureteroscopy (aspirin 82%, clopidogrel 50%, warfarin 40%) and least likely to continue prior to TURP (aspirin 45%, clopidogrel 2%, warfarin 2%). When an antithrombotic agent was discontinued preoperatively and recommenced postoperatively, the number of days to postoperative recommencement varied widely (range: 1 to >15 days pre- and postoperatively). Sixty percent (108/180) of respondents that discontinued warfarin routinely administered bridging therapy with heparin during the perioperative period. Conclusions This is the first study addressing urological procedure-specific perioperative management policies for aspirin, clopidogrel and warfarin. Our findings suggest that perioperative management policies for antithrombotic agents are highly variable and appear arbitrary. Standardised guidelines need to be developed to reduce variations in current urological surgical practice.

Treatment options for patients with low risk prostate cancer include radical prostatectomy, radiation therapy, and active surveillance. Among patients treated with radical prostatectomy, prior studies have demonstrated significantly higher biochemical progression rates with surgical delays of 6 months or greater. We determined the impact of surgical delay on radical prostatectomy outcomes specifically in low risk patients.From our radical prostatectomy database we identified men who fulfilled the D'Amico low risk criteria (clinical stage T1c/T2a, prostate specific antigen less than 10 ng/ml, and biopsy Gleason 6 or less). Pathological tumor features and biochemical progression rates were compared between men with and without surgical delay. We used Cox proportional hazards models to examine predictors of biochemical progression.Of 1,111 men who fulfilled the D'Amico low risk criteria, those with a surgical delay of 6 months or more were significantly older, had a higher proportion of African American men, and a lower proportion of clinical stage T2a (vs T1). A surgical delay of 6 months or more was associated with a greater risk of high grade disease at prostatectomy (p = 0.001) and biochemical progression (p = 0.04). The progression-free survival rate was significantly lower among men with a surgical delay. On multivariate analysis with prostate specific antigen and clinical stage, surgical delays of 6 months or more were significantly and independently associated with time to biochemical progression.In men who met the D'Amico low risk criteria, a surgical delay of 6 months or more was associated with significantly worse radical prostatectomy outcomes, including more pathology upgrading and a higher rate of biochemical progression. Low risk patients choosing to defer initial definitive therapy should be counseled regarding the possibility of worse treatment outcomes at a later date.

Compelling evidence supports a genetic component to prostate cancer susceptibility and aggressiveness. Recent genome-wide association studies have identified more than 30 single-nucleotide polymorphisms associated with prostate cancer susceptibility. It remains unclear, however, whether such genetic variants are associated with disease aggressiveness—one of the most important questions in prostate cancer research today. To help clarify this and substantially expand research in the genetic determinants of prostate cancer aggressiveness, the first National Cancer Institute Prostate Cancer Genetics Workshop assembled researchers to develop plans for a large new research consortium and patient cohort. The workshop reviewed the prior work in this area and addressed the practical issues in planning future studies. With new DNA sequencing technology, the potential application of sequencing information to patient care is emerging. The workshop, therefore, included state-of-the-art presentations by experts on new genotyping technologies, including sequencing and associated bioinformatics issues, which are just beginning to be applied to cancer genetics. Cancer Res; 71(10); 3442–6. ©2011 AACR.

Cystic renal disease is very common and the detection of complex cystic masses in the kidney has increased dramatically over the last few decades with increased cross-sectional imaging. Cystic renal cell carcinoma represents 5-7% of all renal tumours. The ability to differentiate between those who are benign from those malignant represents a major challenge. The controversy and difficulty lies in those complex cystic renal masses that lie between Bosniak II and III. This review focuses on the diagnosis and management of complex renal cysts, examining the evidence for biopsy and looks at novel diagnostic techniques.There are varying results in interpretation of complex cysts and this is heavily dependent on interobserver variability. Bosniak classification is a valuable tool for the clinician. Computed tomography remains the gold standard, however, newer diagnostic imaging modalities such as contrast-enhanced ultrasonography is demonstrating promising results. Percutaneous biopsy of these complex lesions would appear to be well tolerated and adequate for diagnosis.The ability to accurately identify complex renal cysts that are malignant remains a major challenge to the clinician. Regularly there is no other way to identify malignant features than to biopsy or continue surveillance. Recent literature would suggest that percutaneous biopsy has a good yield and is accurate in the majority of cases. Current apprehension with regard to iatrogenic complications from percutaneous renal biopsy may be exaggerated, as complication rates are higher in patients with intrinsic real disease rather than this cohort of patients. The overlap in diagnosing Bosniak IIf versus III is heavily influenced by interobserver variability and this needs to be a significant factor in making any decision.

PURPOSE OF REVIEW: To review the latest information on biomarkers in renal cell carcinoma and their use in integrated staging systems. RECENT FINDINGS: The discovery of the Von Hippel-Lindau defect and the hypoxia inducible factor-1alpha transcripted genes has led to an explosion in the understanding of molecular pathways in renal cell carcinoma. The two most prominent biomarkers are carbonic anhydrase IX and vascular endothelial-derived growth factor. Carbonic anhydrase IX has demonstrated excellent specificity and ability to predict treatment response. Vascular-derived growth factor has good correlation with stage, grade and increased levels with adverse survival. Markers such as CXCL16, ADAM10, B7-H1, Ki-67, survivin, P53, GLUT-1, calveolin-1 and endoglin are continuously being validated. CXCL16 is one of the newest biomarkers, is significantly expressed in papillary renal cell carcinoma and is an independent prognostic marker for better patient survival. The incorporation of biomarkers into integrated staging systems such as UCLA Integrated Staging System, SSIGN and Bioscore are discussed and compared. SUMMARY: The use of novel molecular biomarkers are being incorporated into clinical practice. The understanding of molecular pathways will lead to tailored treatment to the individual patient.

Mechanical bowel preparation (MBP) and antibiotics (oral and/or intravenous) have historically been used to decrease infectious complications in surgeries that involve manipulation of bowel or potential risk of injury. The use of MBP has recently been challenged in the colorectal surgery literature, thus inspiring similar critical evaluation of our practices in urology. This review gives a brief overview of the history of mechanical and oral antibiotic bowel preparation, as well as the evolution of the practice trends in colorectal surgery and urology. We also examine contemporary guidelines in skin preparation as well as antimicrobial prophylaxis before surgery.

Introduction: We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN).Methods: We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.Results: The median follow-up was 41 months (range: 12–157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs.74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943–2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967–3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement.Conclusions: The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Renal artery pseudoaneurysm (RAP) is a rare complication of partial nephrectomy, but is usually effectively managed with renal vessel embolisation. We report a particularly challenging case of a patient with chronic kidney disease (CKD) who developed a RAP following a laparoscopic heminephrectomy and was treated using superselective renal vessel coil embolisation with carbon dioxide (CO2) as the primary contrast agent for arteriographic localisation of the RAP and feeder artery. To the best our knowledge we report the first utilisation of CO2 arteriography in the definitive diagnosis and treatment of RAP following heminephrectomy in a patient with severe CKD.

We aimed to understand the characteristics of patients who are less likely to submit adequate urine collections at metabolic stone evaluation.Inadequate urine collection was defined using two definitions: (1) Reference ranges for 24-hour creatinine/kilogram (Cr/24) and (2) discrepancy in total 24-hour urine Cr between 24-hour urine collections. There were 1502 patients with ≥1 kidney stone between 1998 and 2014 who performed a 24- or 48-hour urine collection at Northwestern Memorial Hospital and who were identified retrospectively. Multivariate analysis was performed to analyze predictor variables for adequate urine collection.A total of 2852 urine collections were analyzed. Mean age for males was 54.4 years (range 17-86), and for females was 50.2 years (range 8-90). One patient in the study was younger than 17 years old. (1) Analysis based on the Cr 24/kg definition: There were 50.7% of patients who supplied an inadequate sample. Females were nearly 50% less likely to supply an adequate sample compared with men, P0.001. Diabetes (odds ratio [OR] 1.42 [1.04-1.94], P=0.026) and vitamin D supplementation (OR 0.64 [0.43-0.95], P=0.028) predicted receiving an adequate/inadequate sample, respectively. (2) Analysis based on differences between total urinary Cr: The model was stratified based on percentage differences between samples up to 50%. At 10%, 20%, 30%, 40%, and 50% differences, inadequate collections were achieved in 82.8%, 66.9%, 51.7%, 38.5%, and 26.4% of patients, respectively. Statistical significance was observed based on differences of ≥40%, and this was defined as the threshold for an inadequate sample. Female sex (OR 0.73 [0.54-0.98], P=0.037) predicted supplying inadequate samples. Adequate collections were more likely to be received on a Sunday (OR 1.6 [1.03-2.58], P=0.038) and by sedentary workers (OR 2.3 [1.12-4.72], P=0.023).Urine collections from patients during metabolic evaluation for nephrolithiasis may be considered inadequate based on two commonly used clinical definitions. This may have therapeutic or economic ramifications and the propensity for females to supply inadequate samples should be investigated further.

Introduction: Renal trauma accounts for 5% of all trauma cases. Rare mechanisms of injuries including sports participation are increasingly common. Rugby-related trauma poses a conundrum for physicians and players due to the absence of clear guidelines and a paucity of evidence. Our series highlights traumatic rugby-related renal injuries in our institution, and emphasize the need for international guidelines on management. Methods: A retrospective review of all abdominal traumas between January 2006 and April 2013, specifically assessing for renal related trauma that were secondary to rugby injuries was performed. All patients' demographics, computerized tomography results, hematological and biochemical results and subsequent management were recorded. Results: Five male patients presented with rugby-related injuries. Mean age was 21 years old. All patients were hemodynamically stable and managed conservatively in acute setting. One patient was detected to have an unknown pre-existing atrophic kidney that had been subsequently injured, and was booked for an elective nephrectomy an 8-week interval. Conclusion: Rugby-related trauma has generated essential attention. This paper serves to highlight this type of injury and the need for defined guidelines on role of imaging and international consensus on timing of return to contact sport, in both professional and amateur settings.

Introduction: Renal cell carcinoma (RCC) represents about 3% of adult malignancies in Ireland. Worldwide there is a reported increasing incidence and recent studies report a stage migration towards smaller tumours. We assess the clinico-pathological features and survival of patients with RCC in a surgically treated cohort.Methods: A retrospective analysis of all nephrectomies carried out between 1995 and 2012 was carried out in an Irish tertiary referral university hospital. Data recorded included patient demographics, size of tumour, tumour-node-metastasis (TNM) classification, operative details and final pathology. The data were divided into 3 equal consecutive time periods for comparison purposes: Group1 (1995-2000), Group 2 (2001-2006) and Group 3 (2007-2012). Survival data were verified with the National Cancer Registry of Ireland.Results: In total, 507 patients underwent nephrectomies in the study period. The median tumour size was 5.8 cm (range: 1.2-20 cm) and there was no statistical reduction in size observed overtime (p = 0.477). A total of 142 (28%) RCCs were classified as pT1a, 111 (21.9%) were pT1b, 67 (13.2%) were pT2, 103 (20.3%) were pT3a, 75 (14.8%) were pT3b and 9 (1.8%) were pT4. There was no statistical T-stage migration observed (p = 0.213). There was a significant grade reduction over time (p = 0.017). There was significant differences noted in overall survival between the T-stages (p < 0.001), nuclear grades (p < 0.001) and histological subtypes (p = 0.022).Conclusion: There was a rising incidence in the number of nephrectomies over the study period. Despite previous reports, a stage migration was not evident; however, a grade reduction was apparent in this Irish surgical series. We can demonstrate that tumour stage, nuclear grade and histological subtype are significant prognosticators of relative survival in RCC.

INTRODUCTION AND OBJECTIVES: Urosepsis is a complication of percutaneous nephrolithotomy (PCNL) that can occur despite sterile urine and studies have suggested that one week of prophylactic antibiotic therapy can reduce the risk of systemic inflammatory response syndrome (SIRS) and infectious complications in high risk patients with sterile urine. Approximately one-third of upper urinary tract stones harbor virulent microorganisms despite antibiotic therapy. Since antibiotic levels reach a steady state after only 48 hours, our goal was to determine whether antimicrobial therapy of 2 days is as effective as 7 days in preventing SIRS and infectious complications after PCNL. METHODS: We retrospectively reviewed 135 consecutive PCNLs performed by a single surgeon at one institution between January 2012 and October 2013. Preoperative urine cultures were obtained on all patients and positive cultures treated appropriately. Patients with sterile urine were divided into low or high risk (previous UTI, dilated pelvicaliceal systems or stones iÝ 20mm). Patients in the high risk group were treated with either 7 or 2 days antibiotics prior to PCNL. Antibiotic related adverse events and infectious outcomes were recorded for all patients and evaluated using univariate cumulative logit regression analysis. RESULTS: Of the 135 patients, 83 (61.5%) had sterile urine of which 59 (43.7%) met high risk criteria and were treated with either 7 days (31 pts) or 2 days (28 pts) preoperative antibiotics. Both groups were similar in age, gender, and duration of surgery. Comparing 7 vs 2 days treatment there was plevicalyectasis in 11 (35.5%) vs 8pts (28.6%), stone >20mm in 26 (83.8%) vs 23 (82.1%), and previous UTI in 15 (48.4%) vs 11pts (39.3%). There were 15 (25.4%) positive stone cultures overall, (10 pts in the 7 day group and 5 in the 2 day group). No patients in either group had a fever (temp >38.5), met SIRS criteria or developed a postoperative infection or sepsis after PCNL. There were no antibiotic associated complications. CONCLUSIONS: Prophylactic antibiotics for either 7 or 2 days prevented fever, SIRS and infectious complications in our high-risk patients with sterile urine before PCNL. This finding should be confirmed in a larger prospective trial. In the meantime, our results suggest that 2-days prophylactic antibiotics are equivalent to 7-days in reducing the risk of infectious complications after PCNL.

We report a case of a 61-year-old gentleman who presented with frank hematuria with associated weight loss and on-going left knee pain. Subsequent investigation revealed a muscle invasive bladder carcinoma with a related unusual bone metastasis. Though bone metastases form bladder carcinoma are common, frequent deposition sites include the spinal column and pelvis. This case report is to the best of our knowledge the first reported case of a tibial metastasis for relevant bladder carcinoma. Furthermore, we reviewed the literature, relevant diagnostic and management surrounding such occurrences.

Introduction: Fracture of the penis is a rare urological emergency which occurs as a result of abrupt trauma to an erect penis. There is paucity of data regarding long-term sexual function or erectile potency following fracture of the penis. The aim of this study is to objectively assess the overall sexual function following fracture of the penis.Methods: A retrospective analysis of 21 penile fractures was performed. A voluntary telephone questionnaire was performed to assess long term outcomes using three validated questionnaires-the Erection Hardness Grading Scale, the International Index of Erectile Function (IIEF-5) and the Brief Male Sexual Function inventory (BMSFI).Results: The mean age was 33.1 years (range: 19-63). The median follow up was 46 months (range: 3-144). All fractures were a result of sexual misadventure and all were surgically repaired. There were two concomitant urethral injuries. Seventeen patients were contactable. Fourteen patients demonstrated no evidence of erectile dysfunction (ED) (IIEF-5>22), 1 patient reported symptoms of mild ED (IIEF-5, 17-21) and one patient reported mild to moderate ED (IIEF-5, 12-16). No patients reported insufficient erection for penetration (EHGS: 1 or 2). Regarding the overall BMSFI, 13 (83%) patients were mostly satisfied or very satisfied with their sex life within the previous month.Conclusion: In a small surgical series of men with penile fracture managed within a short time frame from presentation, we demonstrate erectile potency is maintained. Long-term overall sexual satisfaction is promising.

Introduction Bowel preparation was established as part of the pre-operative course for patients undergoing ileal conduit formation since the late 1970's. Rationales for its use include reduction in infection and wound complications, technically easier anastomosis and earlier return to bowel function. However, recent reports have challenged this practice. Traditionally antibiotics were also administered for several days prior to surgery with the assumption that bacterial load was reduced. Modification of antibiotic protocols resulted from evidence-based findings. Furthermore, publications emphasizing the benefit of Enhanced Recovery Protocols/Programmes (ERP) have become contemporary. Methods An online multiple-choice questionnaire (via Monkey Survey ® ) was administered to all consultant urologists in Ireland. This national cross-sectional study evaluated the use of bowel preparation and antibiotic prophylaxis prior to urinary diversion. In addition, we also assessed consultant urologists' awareness of ERP and their views on the introduction and implementation of such a national program. Results Of the 41 consultant urologists surveyed, 80.4% ( n = 33) responded. 63.6% routinely used bowel preparation. Klean Prep ® was the most commonly used bowel preparation. 80.9% of urologists admit their patient's one-day pre-operatively for bowel preparation, with 87.8% using antibiotic prophylaxis at anesthesia induction, and 18.1% continuing the antibiotics for 24–48 h post-operatively. Although 74% of consultants are aware of ERP, only 66.6% are in favor of their national implementation. Conclusion The majority of Irish urologists use bowel preparation prior to ileal conduit formation. Substantial recent evidence has emerged showing no difference in infective complications or anastomotic leakage when bowel preparation was not used. National guidelines would be beneficial regarding the use of bowel preparation, antibiotic prophylaxis and ERP for urinary diversion surgery.

Objective To identify the incidence and features of significant incidental findings discussed at our departmental multidisciplinary team meeting (MDM). The improved quality of radiological imaging has resulted in increased rates of incidental findings. Although some may be trivial, many have clinical significance and early diagnosis and treatment may be beneficial. Methods A retrospective analysis was performed of all cases discussed at the MDM between January 2012 and February 2013. Cases were divided into two groups – Group 1 consisted of patients whose initial imaging was performed for a urological presentation which resulted in a synchronous finding; Group 2 consisted of patients who were referred with a synchronous urological finding for discussion following investigation of an initial benign urological condition or a non-urological condition. Results 696 patients were discussed at 53 MDMs. 109 (15.7%) patients had incidental findings. 61 (56%) of these were in Group 1. 16 (26.2%) were synchronous malignant diagnoses, 25 (41%) were benign and 20 (32.8%) were indeterminate. 48 (44%) patients in Group 2 – 40 (83.3%) were renal in origin and 30 (75%) of these proceeded to surgery. The median tumour size was 3.2 cm (Range: 1.2 cm–10 cm). One patient had radio-frequency ablation. Two were referred for palliative care. Seven patients are under ongoing surveillance – the median size of these lesions is 3.6 cm (Range: 2.1 cm–8.3 cm). Conclusion A substantial workload is generated from the investigation of incidental findings discussed at MDM – these now represent the majority of the caseload for renal cancer surgery.

Diagnosis of prostate cancer (PCa) in elderly men poses a serious challenge to most clinicians, with many of the opinion that radical treatment may result in complications affecting quality of life, and question whether if treated or untreated, the patient is likely to live long enough to die of the disease. However, there is good evidence that these cancers have worse tumor characteristics than those in younger men. In elderly patients, the number and severity of comorbid conditions and functional impairments are strong predictors of life expectancy. Recently, the International Society of Geriatric Oncology Prostate Cancer Working Group (SIOG) published guidelines on the management of PCa in men over the age of 70 and advises the approach should be the same as in younger men but tailored to their individual health status. To assist in decision-making, there are many tools available both in assessment of men in terms of comorbidity and eligibility for curative treatment, as well as nomograms to predict life expectancy in men with or without comorbidity following curative treatment. In this chapter, we describe the tumor and clinical characteristics of PCa’s in this age group, the importance of comorbidity and not age in terms of assessment, and the tools available to the clinician; discuss life expectancy and predictors of survival; and report on the recent guidelines from SIOG.

To evaluate prospectively the characteristics, erectile function and lower urinary tract symptoms (LUTS) of men undergoing prostate needle biopsy (PNBx).From 2008 to 2011, 134 men were prospectively administered the International Index of Erectile Function (IIEF), American Urological Association Symptom Index (AUA-SI), and quality-of-life (QoL) questionnaires before and after undergoing a single 12-core PNBx. Comparisons of IIEF and AUA-SI scores before and after PNBx, based upon baseline characteristics and prostate cancer (PCa) diagnosis, were performed. Univariable and multivariable logistic regression models were used to characterize predictors of change in IIEF scores.In the 85 men who fulfilled the inclusion criteria, there were no significant differences between the mean (sd) total pre-biopsy and the mean (sd) post-biopsy IIEF scores: 57.8 (12.9) vs 54.3 (17.2). Subgroup analysis showed that men who had biopsy-proven PCa had significantly greater changes in their post-biopsy IIEF scores compared with men without (-10.1 vs. 1.0; P0.001). After specific analyses of the IIEF domains in these groups we found significant decreases in every domain, including erectile function (P = 0.01). On multivariate analyses, only PCa diagnosis was associated with a significant change in IIEF (odds ratio 7.2; P = 0.003). There were no differences in AUA-SI or QoL scores in the overall population or in subgroups.Cancer diagnosis appears to have an adverse effect on the erectile function of men undergoing PNBx but no effect on LUTS. This study highlights a potential negative psychological confounder that may influence erectile function before the treatment of PCa. Additional prospective trials evaluating these relationships are warranted.

cohort of 434 patients with a total PSA 50 ng/mL who were referred to our institution for an initial prostate biopsy. Outpatient transrectal ultrasound-guided prostate biopsies were performed according to a standardized institutional saturation scheme (18-22 cores). Logistic regression models were fitted to test the predictors of PCa at initial biopsy. Predictive accuracy estimates of biopsy outcome predictions were quantified using the area under the receiver-operating characteristic curve (AUC). Differences in AUCs were tested using the DeLong method. Regression coefficients were used to create a nomogram that was internally validated using 200 bootstrap resamples. Finally, the extent of overestimation or underestimation of the observed PCa rate at biopsy was determined with calibration plots. RESULTS: Overall, 179 (41.2%) patients were diagnosed with PCa at initial extended prostate biopsy. In accuracy analyses, PHI emerged as the most informative independent predictor of PCa (AUC: 74.5%; p 0.001). The inclusion of PHI to a multivariable logistic regression model based on established predictors of PCa (age and digital rectal examination) significantly increased the predictive accuracy of a 3.4% extent (from 75.6 to 79.0%; p 0.001). Calibration of the nomogram was good within the whole range of predicted probabilities. CONCLUSIONS: We developed a nomogram based on PHI that can assist clinicians in the decision to biopsy by giving patients an individual risk of PCa. While internal validation provided evidences of good calibration and accuracy of the tool, external validation of our findings is still required.