News & Views in 2009

Data from a retrospective multicenter study have revealed that the presence of urinary collecting system invasion portends a worse outcome in patients with organ-confined disease. Evidence that cancer has spread into the collecting system, in the context of other adverse prognostic factors, should prompt clinicians to instigate closer follow-up of patients after nephrectomy.

The use of PSA testing as a screening tool for prostate cancer is limited by its low specificity. New data offer insight into how genotypic information might be incorporated into PSA screening approaches to enhance their accuracy.

Denosumab, an inhibitor of RANKL, improves bone mineral density and reduces the incidence of fractures in men who receive androgen deprivation therapy (ADT) for prostate cancer. At present, however, a lack of comparison with potent bisphosphonates limits the assessment of its utility in the prevention of ADT-induced bone loss.

Since 2003, duty hours for US resident physicians have been restricted to 80 h per week. For the first time, a study in a surgical population now demonstrates a reduction in mortality and morbidity associated with the working-hour reform.

In the UK, a patient's residential address can determine whether they have access to certain treatments. An audit of the effect of this 'postcode lottery' on the survival of patients with advanced renal cell carcinoma suitable for treatment with sorafenib or sunitinib highlights the iniquities that can plague such allocation systems.

The R.E.N.A.L. system for classifying tumors aims to predict the surgical challenges of partial nephrectomy. However, the factors involved in surgical planning are many and complex, and are not adequately addressed in this simplified system. The inclusion of oncological features and a 'surgical skills factor' might contribute to its widespread utility.

Robot-assisted partial nephrectomy is an emerging technique that potentially provides advantages over conventional laparoscopic approaches. A retrospective multi-institutional study suggests that robotic technology offers improved outcomes in this setting, even in hands experienced with laparoscopic surgery; however, additional data validating these findings and evaluating complication rates and surgical margins are needed.

Tyrosine kinase inhibitors delay tumor progression and have a favorable adverse effect profile in patients with metastatic renal cell carcinoma; however, the impact of these treatments on objective clinical outcomes remains unknown. Updated results from two landmark phase III randomized trials now demonstrate the effect of sunitinib and sorafenib on survival.

A bladder preserving protocol comprising combined external-beam radiotherapy and interstitial brachytherapy for the treatment of bladder cancer has been reported as a viable alternative to cystectomy. However, we have concerns regarding the oncological efficacy of this approach and believe important quality of life issues need to be addressed.

Insertion of midurethral synthetic slings is now the cornerstone surgical approach to treatment of stress urinary incontinence. A group from Poland randomized 537 women to synthetic sling placement using either a retropubic or transobturator technique. The investigators found both procedures to be equally effective in curing or improving the condition.

Clinical research in recent years has produced a deepening appreciation of the metabolic consequences of androgen deprivation therapy. On the basis of this knowledge, proactive management of risk factors for diabetes and cardiovascular events is appropriate in men who receive this treatment for prostate cancer.

Despite a plethora of clinical trials, no treatment has shown consistent success for symptomatic management in patients with chronic prostatitis–chronic pelvic pain syndrome. Subdividing this heterogeneous patient population according to phenotype, and selecting therapy accordingly, represents an important step forward in the treatment of this disorder.

Considerable costs are incurred when caring for patients with terminal cancer in their last few days of life. With the debate over health care reform in the US being at center stage, focusing primarily on cost reduction, how can we best serve our cancer patients in their final days?

EORTC 22961 is the latest trial to investigate the optimum duration of adjuvant androgen deprivation therapy for patients with locally advanced prostate cancer. The results conclusively show superiority of long-term over short-term treatment, and the former protocol should, therefore, be considered standard of care in this setting.

Patients undergoing CT for the evaluation of stone disease are likely to receive high levels of radiation over time. Although the results from small studies using simulation software suggest that using a reduced radiation dose has little effect on calculi detection, larger prospective randomized studies are required to produce clinically applicable results.

Data indicate that rates of seminal vesicle invasion at prostatectomy are falling, making seminal vesicle sparing surgery more viable, especially in low-risk patients. These changes can be viewed as part of a general trend towards lower-risk cancer at presentation.

The current diagnostic strategy for patients with hematuria incorporates imaging evaluation of the urinary tract to identify the source of the bleeding. Diffusion-weighted MRI offers promise in detecting and characterizing tumors and benign processes of the bladder, and might obviate the need for invasive cystoscopy in this setting.

Topical anesthetics are moderately effective treatments for premature ejaculation. In a 12 week, double-blind RCT, a metered-dose aerosol spray containing lidocaine and prilocaine (PSD502) showed a 6.3-fold increase in intravaginal ejaculatory latency times, improved all patient-reported outcomes and had no serious adverse effects.

There has been little published on the treatment of prostate cancer with external beam radiotherapy doses greater than 5 Gy per fraction.¹ New data from King and colleagues'² series of 41 patients treated with stereotactic body radiotherapy in 5 fractions of 7.25 Gy make an important contribution to our understanding of the radiobiology of prostate cancer and the tolerance of surrounding normal tissues.

Data from a long-term Scandinavian study show that the addition of radiation to long-term androgen deprivation therapy does not affect quality of life in patients with locally advanced prostate cancer. The long-term use of the antiandrogen flutamide might, however, have negatively affected quality of life outcomes for all patients in this study.