News & Views in 2010

The risk of suicide is increased among men diagnosed with prostate cancer, particularly those with metastatic disease. These results indicate a need to identify signs of depression and optimize treatment among newly diagnosed patients.

Despite a promising response rate and good tolerability profile, phase III randomized trial data do not justify the use of pazopanib for metastatic renal cell carcinoma over existing treatment options. Evidence confirming efficacy superior to sunitinib or everolimus is required to justify its consideration in first-line or second-line therapy, respectively.

Patients diagnosed with clinical stage I (CS I) nonseminomatous germ cell tumors (NSGCT) have excellent survival. There are several therapies that contribute to this outcome and choosing among them can be challenging for both patient and physician. A decision tree analytical approach has been proposed, which incorporates quality of life outcomes and survival data to quantitatively determine the optimal approach for individual patients with CS I NSGCT.

A large study has found no improvement in overall survival using a combination chemo-immunotherapy regimen for metastatic renal cell carcinoma, compared with immunotherapy alone. While the development of targeted therapies has provided uro-oncologists with a wider variety of treatment options, immunotherapy retains an important role in the management of metastatic renal cell carcinoma.

A randomized controlled trial published in European Urology concludes that combination therapy with tamsulosin and dutasteride is superior to monotherapy with either of these therapies in reducing the risk of clinical progression of benign prostatic hyperplasia. This approach might prove an attractive option for men who have troublesome symptoms and wish to avoid surgery.

Tumor stage distribution in the population of patients with metastatic renal cell carcinoma (mRCC) enrolled in first-line clinical trials has changed over time, with a significant shift of patients to more-favorable risk groups. This phenomenon might result in difficulty recruiting for high-risk mRCC clinical trials and possible overestimation of the benefits of new treatment regimens.

Small renal tumors are generally managed by partial nephrectomy; however, positive surgical margins are occasionally found on final pathologic examination. Growing evidence suggests that the presence of positive margins does not adversely affect outcomes; these patients can potentially be managed expectantly with close follow-up without compromising oncological efficacy.

Use of a multivariable 'Riskindicator' model might increase the accuracy of screening for clinically significant prostate cancer. Such models, in conjunction with novel biomarkers, hold promise for improving the specificity of screening, and could help to reduce the number of unnecessary biopsies performed in this setting.

Before 2009, no controlled trials of percutaneous tibial nerve stimulation (PTNS) for overactive bladder had been reported. However, publication of a randomized unblinded tolterodine-controlled trial of PTNS and the reporting of two blinded placebo-controlled studies now provide level 1b evidence of efficacy. PTNS should, therefore, be considered as a treatment option in this setting.

Ischemic priapism can result in erectile dysfunction if unresponsive to treatment. A recent study advocates immediate penile prosthesis implantation in patients with treatment-refractory ischemic priapism to avoid loss of penile length and to facilitate insertion of the prosthesis. Such a protocol may well become the standard of care in future.

No established definition exists of therapeutic success after high-intensity focused ultrasound in patients with localized prostate cancer. A recent analysis has proposed a definition of biochemical failure for use in this setting. However, much work still needs to be done on identifying suitable predictors of clinical failure, and large-scale validation is certainly required.

Accurate estimates of treatment success, complications and long-term morbidity are essential for patients to make informed medical decisions regarding treatment. Several multivariate prediction models have been developed to predict patient outcome after radical cystectomy (RC) for bladder cancer. The IBCNC postcystectomy nomogram can improve clinical decision making and therefore patient outcome. The inclusion of biomarkers might improve the accuracy of nomogram predictions in the future.

Current treatment options for clinical stage T1 renal tumors, in patients with a contralateral healthy kidney, are diverse. The first guidelines for the management of these lesions have recently been published, which state that tumor size and health status of the patient are important factors to consider. The inclusion of tumor location, patient age and major comorbidities might strengthen these guidelines in the future.

External beam radiation therapy and cryoablation can both be used to treat localized prostate cancer. Quality of life outcomes are similar with the two forms of treatment, with the exception of sexual function, which is poorer in patients treated with cryoablation than in those who receive radiation therapy.

A recent study using claims data to compare open retropubic with minimally invasive prostatectomy has revealed higher rates of genitourinary complications, incontinence and erectile dysfunction after the laparoscopic procedure. However, there are a number of inherent problems associated with the use of claims-based diagnoses for the evaluation of surgical techniques.

Antimuscarinic therapy for children with overactive or neurogenic bladder is limited by its suboptimal efficacy and tolerability. New research suggests that double antimuscarinic treatment can improve continence and urodynamic parameters with an acceptable rate of adverse effects. Although the study was small and uncontrolled, it provides the impetus for larger randomized double-blind analyses.

An article in The Journal of Urology addresses a frustrating feature of PSA-based prostate cancer screening, namely the fact that PSA is a fairly nonspecific marker for cancer. The authors provide a potential diagnostic test for the most common non-cancer diagnosis on prostate biopsy—asymptomatic inflammatory prostatitis (AIP)—and recommend its use as a means of avoiding unnecessary prostate biopsies.

Neoadjuvant targeted therapy can be used in patients with unresectable locally advanced, locally recurrent or metastatic renal cell carcinoma to induce cytoreduction before surgical resection. The efficacy of this multimodal therapy is still unproven, however, and must be balanced against a potential higher risk of perioperative complications.

The relationship between trial registration and publication is not straightforward. Although registries and editorial requirements receive some attention from researchers, study protocol changes, omissions and suppressions are the rule. Such practices deny patients and their health-care providers access to unbiased clinical information on which to base decisions.

Intravesical instillation with live, attenuated Mycobacterium Bacillus Calmette-Guérin (BCG) is an effective therapy for bladder cancer. Two recent analyses provide new insight into the clinical efficacy of BCG versus chemotherapy with mitomycin C in intermediate-risk and high-risk bladder cancer.