News & Views in 2011

Despite considerable interest in focal therapy for patients with prostate cancer, no universally accepted criteria exist to identify candidates. A new study now suggests that accurate patient identification for focal therapy is not possible using conventional techniques. New tools are required to precisely characterize and localize tumors.

The use of ureteral stents is an integral part of the surgical management of upper tract urinary lithiasis. Recent evidence suggests that stenting after “uncomplicated” ureteroscopic lithotripsy could be unnecessary, but what constitutes an “uncomplicated” case, and is this evidence convincing enough to change current practice?

Cancer survivors represent a burgeoning patient population at risk of recurrence and comorbidity. Their needs are great and we must find ways to deliver care that optimizes health, without “breaking the bank.” Fragmentation of care contributes to higher health-care costs, so strategies that reduce redundancy while preserving quality of care are essential.

A recent cross-sectional study has evaluated the outcomes of currently used medical strategies for the treatment of LUTS in France, showing that treatment was unsatisfactory in about half of these patients. It is not clear whether this is due to the limited therapeutic effect of the available drugs or to their suboptimal use.

Warm ischemia time during partial nephrectomy is an important risk factor for renal failure after surgery. A new study proposes using anatomic vascular microdissection of renal artery branches to perform zero-ischemia partial nephrectomy. Although the results are promising, the technique is challenging and requires further evaluation.

Urinary incontinence is a common condition among older adults. Numerous clinical guidelines have been published with recommendations for incontinence evaluation and management, especially in women. However, practitioner adherence to guidelines is often poor, particularly for elderly patients. What influences this trend? Is it a form of ageism in health care?

The management of infants and children with a febrile UTI is controversial. In the past, children have undergone extensive diagnostic imaging, but recent studies suggest these procedures are unnecessary. The new US guidelines recommend reduced use of radiological investigations and also suggest that prophylactic antibiotics are, at best, of limited benefit.

A repeat biopsy procedure is performed in patients with suspicion of prostate cancer after initial biopsy. However, the optimal strategy for repeat biopsy is not known. A new study now elucidates the ideal number and location of cores according to each patient's tumor characteristics. Further validation will be required.

Accurate prediction of Gleason grade before treatment begins is crucially important in decision-making because it is a predictor of prostate cancer aggressiveness. A recent study has reported that biopsies targeted towards the most abnormal regions on 3T diffusion-weighted imaging could improve the accuracy of the assessment of true tumor aggressiveness.

For years, the standard protocol when performing a partial nephrectomy has been to leave a drain for monitoring postoperative complications, such as urinary fistulae and hemorrhage. Contemporary literature is now suggesting that, in select cases, drain placement (with its associated morbidity) might be unnecessary.

The erectile function domain of the International Index of Erectile Function score is a widely used patient-reported outcome metric and a frequent clinical trial end point. Rosen and colleagues determined minimal clinically important difference (MCID) values for this score to overcome discrepancies between statistical significance and clinical significance. Before these MCIDs are implemented in the clinic, urologists should be aware of the advantages and limitations of this instrument.

There are several options for treating clinically localized renal tumors in the elderly, ranging from active surveillance to radical nephrectomy. Reduced renal function is associated with increased cardiovascular mortality, so maintaining renal function is of the utmost importance. Personalized therapy should be based on tumor location, comorbidities and general health status rather than tumor size and patient age.

Prostate cancer screening has led to an increase in transrectal-ultrasonography (TRUS)-guided prostate biopsies. However, clinicians are becoming increasingly concerned that fluoroquinolone-resistant organisms are the cause of infectious complications in patients who have undergone this procedure. Two separate studies have shown that patients treated with fluoroquinolone prior to transrectal biopsy are at an increased risk of infectious complications.

International prostate symptom score is widely used to evaluate lower urinary tract symptoms in patients with benign prostatic hyperplasia. However, the questions can be difficult to understand for some patients, leading to inaccurate treatment decisions. A visual prostate symptom score could overcome this limitation, but should be further investigated.

For decades, complete removal of the kidney with all the contents of the Gerota's fascia (including the adrenal gland) has been a standard procedure for treating renal cell carcinoma (RCC). Two recent articles argue against routine adrenalectomy, and encourage adrenal preservation for the vast majority of patients with RCC.

Passing kidney calculi can be excruciatingly painful for patients, likened to childbirth in intensity. The mechanism of the simple act of passing a stone, however, is not well understood. A recent research article examined a novel approach for optimizing kidney stone clearance—sleep position, a simple noninvasive concept that might improve urinary stone passage.

Radiation exposure is inevitable when using fluoroscopy for ureteroscopic procedures. However, there are numerous acute adverse effects of radiation, and the long-term effects are unclear. Thus, efforts to minimize the use and duration of fluoroscopy are essential for the benefit of not only the patients, but also the surgeons carrying out the procedure.

A multicenter randomized trial comparing a trocar-guided mesh kit to anterior colporrhaphy for treatment of cystocele adds to evidence that transvaginal mesh for treatment of anterior vaginal prolapse improves anatomical outcomes at the expense of greater complications. Careful consideration of benefits and risks is required when considering transvaginal mesh for prolapse repair.

The European Organisation for Research and Treatment of Cancer (EORTC) tables estimate risks of tumor recurrence and progression in patients following transurethral resection of non-muscle-invasive bladder cancer. But how well do the predictive accuracy and discriminative ability of the tables stand up in patients administered bacillus Calmette–Guérin (BCG)?

Although various male sling techniques are available, artificial urinary sphincter surgery (AUS) remains the treatment of choice for male stress urinary incontinence. A recent article has described the surgical learning curve for reoperation rates after AUS implantation, finding that there was no plateau, even with very experienced surgeons.