News & Views in 2014

A key study comparing radical prostatectomy and watchful waiting for prostate cancer has been updated with extended follow-up observation, demonstrating substantial benefits of surgery for reduced mortality mainly in younger men, but also reduced requirement for palliative treatment in older men. These findings should be interpreted within the current scenario of prostate cancer diagnosis and treatment.

Two major trials have been performed to determine the effect of 5α-reductase inhibitors on subsequent diagnoses of prostate cancer. Both trials showed that high alcohol intake significantly increased prostate cancer risk among men allocated to the treatment arms. The recommendation that patients eliminate alcohol when taking 5α-reductase inhibitors seems appropriate.

Use of clinically active agents, such as kinase inhibitors, before nephrectomy is safe and feasible and can decrease the size of primary tumours, enabling optimization of the surgical approach. However, the overall clinical benefit of the neoadjuvant use of toxic drugs, such as axitinib, has not yet been demonstrated.

A new report of zoledronic acid in men with high-risk prostate cancer is the latest in a long line of negative studies that have addressed the prevention of metastasis. We must learn from these studies so that potentially useful agents are not discarded due to poor trial design in the future.

Concerns have been raised regarding the educational value of live surgical events (LSEs) and whether such events compromise patient safety. Now, the European Association of Urology has published a Live Surgery Policy Statement, aimed at protecting patient safety and ensuring that LSEs are conducted in an ethical and accountable manner.

Unfortunately, the noble aims of the Melbourne Consensus statement on the early detection of prostate cancer lack rigour, failing to take into account the breadth of evidence in this field; as a result, they fall disappointingly short of providing clarity on this important issue.

Currently, numerous systems exist for the identification of high-risk prostate cancer, but few of these systems can guide treatment strategies. A new stratification tool that uses common diagnostic factors can help to predict outcomes after radical prostatectomy. The tool aids physicians in the identification of appropriate candidates for aggressive, local treatment.

Focal therapy of prostate cancer enables treatment of the index lesion while sparing the rest of the gland and surrounding vital structures, thereby decreasing the risk of morbidity. As clinicians acknowledge its potential, the recently published multidisciplinary consensus is timely and provides new insight into trial design for focal therapy.

New research shows that high-risk and intermediate-risk prostate cancers are being treated with brachytherapy alone, deviating from both guidelines and expert opinion. These findings should force intense introspection and scrutiny amongst clinicians, and encourage them to consider whether they are practicing evidence-based medicine.

Advances in available treatments for metastatic renal cell carcinoma affect the prevalence, morbidity, and mortality associated with skeletal-related events (SREs) owing to metastatic bone lesions. A newly published report shows that the prevalence and in-hospital mortality of SRE-associated hospitalizations are decreasing, while the associated costs are increasing.

Although multiple systemic treatment options are available for men with castration-resistant prostate cancer, there is a paucity of data regarding optimal sequencing of these drugs. A recent study suggests that cabazitaxel exerts antitumour activity in men who have been pretreated with docetaxel and abiraterone or enzalutamide.

A newly published randomized controlled trial shows that pelvic floor muscle training can significantly reduce prolapse symptoms compared with provision of a prolapse lifestyle advice leaflet and no muscle training. However, the important role of surgery in the treatment of these women must be taken into account.

Sentinel lymph node biopsy is used for tumour staging of many cancers. In new research, a fluorescent, radiolabelled tracer gave equivalent radiographic localization and improved visualization of sentinel nodes in penile cancer, compared with current standard tracers, but technical and financial considerations could influence its widespread use.

A lack of evidence exists regarding the role of nonsystemic treatments for men with metastatic prostate cancer. According to a recently published series of patients with metastatic disease at diagnosis, primary tumour treatment could improve rates of patient survival.

A recent retrospective study reporting increased risk of cardiovascular events and death with testosterone therapy has received extensive media attention. However, the authors' conclusions are highly questionable given the extensive data manipulation and serious methodological errors. Indeed, a rich body of literature strongly suggests that testosterone therapy offers cardiovascular benefits.

Despite increased use of robot-assisted radical prostatectomy (RARP), there is still a paucity of data defining the learning curve associated with this approach. A recent study suggests superior quality-of-life outcomes and improved surgical margin rates are achievable after a long learning curve for open surgeons who undertake RARP.

The EAU has issued the first clinical practice guidelines on priapism, which have been published in short form in European Urology. Put together by the EAU panel on male sexual dysfunction, these guidelines provide an accessible, structured guide for the diagnosis and treatment of this rare clinical disorder.

Implementing a well-structured laparoscopic training curriculum during urology residency has proven to be challenging. The results of the European Training in Basic Laparoscopic Urological Skills (E-BLUS) examination show low levels of proficiency in laparoscopic techniques for urology residents completing training. What must be done to improve these standards?

Few series have reported on the incidence of lymph node metastases, multimodal treatment, and long-term outcomes associated with extended pelvic lymph node dissection in large cohorts of patients with surgically treated prostate cancer. The first nomograms for predicting prognosis from such data have only recently been developed and internally validated.