Reviews & Analysis

Long awaited data from the clinical investigation of bladder cancer in both the neoadjuvant and adjuvant settings were released in 2011, setting the stage for the next generation of work in this area. The findings of a number of studies provide the first steps towards a personalized approach to this disease.

Contemporary treatment guidelines for the localized renal mass are largely driven by expert opinion and retrospective observational data. Three articles published in 2011 add important information to the existing body of literature, enabling improved objectification of risk and individualization of clinical tradeoff decisions for patients presenting with localized renal tumors.

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.

Molecular biomarkers have been largely excluded from current management algorithms for urologic malignancies. This Review focuses on molecular biomarkers that could potentially be used to diagnose and prognose patients with bladder cancer, as well as markers with potential for forecasting and stratifying responses to emerging targeted therapies.

Detrusor smooth muscle (DSM) defects are responsible for some forms of bladder dysfunction, such as overactive bladder secondary to detrusor overactivity. In this Review, the author examines the role of K⁺channels in normal and dysfunctional DSM, the methods used to study their activity, and how these channels might be targeted therapeutically with the use of gene therapy approaches and specific inhibitors or activators.

Genitourinary tuberculosis (GUTB) is the second most common form of extrapulmonary TB, with more than 90% of cases occurring in developing countries. In this Review, Abbara and Davidson present the epidemiology and pathophysiology of TB and describe the diagnostic tests and imaging techniques. They also elucidate the sites of GUTB in men and women and explain the treatment options. Future challenges for the management of drug-resistant patients and those with HIV co-infections are also considered.

2011 was a breakthrough year for the treatment of castration-resistant prostate cancer. The encouraging results of two large clinical trials were reported, as well as data identifying a number of promising new therapeutic targets. Bone-modulating agents continued to show potential for the prevention of skeletal events.

Asymptomatic bacteriuria (ABU) is defined by the presence of bacteria in the urine of a patient without signs or symptoms related to UTI. A common condition that is often treated unnecessarily with antibiotics, ABU should be detected and treated in pregnant women and patients undergoing urologic surgery, but in most other patient groups, treatment does not confer benefit and can be harmful. In this Review, Trautner discusses the science behind ABU, when it should be treated, and what is being done to change the prescribing behavior of physicians managing a patient with ABU.

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.

Cisplatin-based chemotherapy is standard of care for patients with transitional cell bladder cancer; however, many of these patients suffer from renal impairment and are considered unfit for such treatment. Nicholson discusses whether this degree of caution is warranted, and what alternatives should be considered in patients for whom cisplatin is genuinely contraindicated.

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.

The use of robot-assisted laparoscopic technology is rapidly expanding, with applicability in numerous disciplines of surgery. At present, there are very few published guidelines for the safe introduction of urologic robotic surgery (RS) at an institution. In this Review, Liberman and colleagues focus on some of the key aspects of postgraduate and residential RS training.

The hollow and mobile nature of the bladder leads to considerable variations in volume, shape and position of this organ over time, making delivery of radiation therapy to bladder tumors a challenging exercise in planning. In this Review, the authors describe the use of various imaging modalities to improve the accuracy and effectiveness of radiation therapy in patients with bladder cancer.

Radical cystectomy with subsequent urinary diversion has been assessed the most difficult surgical procedure in the field of urology. In this Review, the authors discuss the need for standardized reporting of complications after urinary diversion, and summarize our current knowledge of the complications associated with different diversion techniques.

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.