News & Views in 2010

Transurethral resection (TUR) is widely used to manage early-stage bladder cancer. A recent study has confirmed that a second, or restaging, TUR is associated with a lower risk of progression and cancer-related death. Restaging TUR is therefore recommended as a standard of care in patients with stage T1 bladder cancer.

Controversies remain regarding the precise cell type from which prostate cancers originate. In the last 2 years, two separate studies have arrived at apparently conflicting models for the cell type involved in prostate cancer initiation. However, these results are not mutually exclusive: there are potential solutions, and alternative views on the initiating cell derivation of prostate tumors also exist.

Androgen deprivation therapy (ADT) is well established as a cause of osteoporosis and increased fracture risk. A study has shown that toremifene reduces fracture risk in men receiving ADT for prostate cancer. The study has substantial limitations, however, and the management of bone disease in these patients remains a challenge.

Hypothyroidism is a commonly reported side effect of treatment with sunitinib and sorafenib. A recent study has correlated development of subclinical hypothyroidism with clinical outcome, notably response rate and overall survival, in patients with metastatic renal cell carcinoma who are being treated with these drugs.

Timed voiding is an important part of urotherapy, the preferred first management option in children with urinary incontinence. A Danish randomized controlled trial has shown that the use of a watch set with alarms to remind the child to void significantly improves adherence to the timed voiding regimen, resulting in better daytime continence.

Results from a Swedish study have suggested that the risk of inguinal hernia following prostatectomy is higher in men undergoing open surgery than in those treated via a robot-assisted laparoscopic technique. Patients should be made aware of this risk during the informed consent process.

Late-onset hypogonadism (LOH) is frequently difficult to diagnose in middle-aged and elderly men. A recent study has reported that a cluster of three sexual symptoms and a total testosterone threshold of less than 11 nmol/l are important determinants for the diagnosis of LOH in this age group.

The average age of men diagnosed with prostate cancer is falling, and thus the burden of morbidity associated with its treatment is of great interest. Physicians want to provide their patients with definitive cancer treatment, but without the morbidity which is associated with surgery and radiotherapy. Ablative therapy, using modalities such as high-frequency focused ultrasound (HIFU), offers an exciting prospect for in situ definitive treatment of prostate cancer, with a theoretical reduction in associated adverse effects.

Blue-light cystoscopy is a method of photodynamic diagnosis (PDD) used in the bladder which offers an opportunity to improve the quality of the endoscopic diagnosis and treatment of bladder cancer by enhancing the color contrast between tumor and non-tumor tissue. Introduced in Germany¹ nearly 20 years ago, a substantial body of evidence, including a recent paper by Geavlete et al.,² suggests that PDD markedly improves the completeness of the initial resection in transurethral endoscopic surgery.

The MiniArc^™ sling is a next generation midurethral sling that is placed through a single incision with anchoring tips that fix into the obturator muscles. A new study reports 12-month success rates for this sling ranging from 85–91%, depending on the outcome measure evaluated, with a low rate of adverse events. Despite these encouraging results, long-term data are needed to demonstrate distinct advantages of the MiniArc^™ over existing slings, combined with proven efficacy and safety.

The Surgical Care Improvement Project (SCIP) aims to reduce complications by ensuring adherence to a number of procedural criteria. The findings of a recent study imply that adherence to individual SCIP infection-prevention measures may not be an effective measure of quality. Rather, 'all-or-none' compliance with multiple SCIP recommendations is required if hospitals are to achieve quality-improvement outcomes.

In the PROG 95-09 trial, higher-dose radiation therapy improved the 10-year biochemical recurrence rate among patients with localized prostate cancer without worsening patient-reported quality-of-life outcomes. This study provides valuable information on health-related quality of life associated with high-dose radiation therapy for prostate cancer, which may assist physicians when counseling patients on their available treatment options.

Initial results of the REDUCE trial suggest that dutasteride decreases the incidence of prostate cancer in men with persistently elevated PSA; however, questions have emerged about the drug's effect on the incidence of high-grade cancer. Adjustment for post-randomization confounders, however, brings the true benefit of this drug into clearer focus.

The recommended treatment for adrenocortical cancer (ACC) is surgical excision. Two studies have compared open versus laparoscopic adrenalectomy for tumor excision in patients with ACC, and have drawn different conclusions on the effectiveness of laparoscopic adrenalectomy in these patients.

Disparities in prostate cancer treatment patterns have been traced to differences in socioeconomic status. These results have implications for quality of care imparted by health-care providers. Until randomized clinical trials establish standards of care, physicians must be wary of unconscious bias and strive to support, not dictate, the decision-making process.

New research confirms that sacral nerve stimulation is a feasible option for treating subjective symptoms of urinary and fecal incontinence in children. However, owing to a lack of correlation between objective and clinical response parameters, we require standardized means of assessing outcomes in this patient population.

Precise localization of prostate cancer is essential for the success of focal therapies. Despite suggestions that saturation biopsy might be useful in this regard, a new study implies it cannot accurately pinpoint prostate tumors. Research efforts would perhaps be better focused on identifying which patients require treatment for clinically localized prostate cancer in the first place.

Once again the question of one versus two 24 h urine collections for diagnosis in kidney stone prevention has been raised. As in all previous studies, no difference is seen in the mean levels of analytes between first and second collections. However, variation within patients is so marked that at least two collections are needed for confidence.

Overall survival after surgical treatment can be difficult to predict in patients with renal cell carcinoma (RCC). A new nomogram uses age, race, sex, and tumor size as predictive factors to determine the risk of death in patients with RCC. This nomogram might prove to be a valuable clinical tool once developed further.

Final results of the CALGB 90206 and AVOREN trials have failed to demonstrate an overall survival benefit for bevacizumab plus interferon compared to interferon monotherapy in patients with metastatic renal cell carcinoma. Progression-free survival or objective response rate might be more suitable primary end points in phase III trials.