Reviews & Analysis

The pursuit of reduced-intensity treatments for testicular cancer continued with vigour in 2013. For those with metastatic disease and poor prognoses, an alternative to bleomycin, etoposide and cisplatin chemotherapy emerged. These advances suggest we are making progress by reducing treatment intensity with personalized approaches for this highly curable malignancy.

Big data and computational biology brought to the forefront a number of potential actionable mutations and drug targets in clear cell renal cell carcinoma in 2013. As we continue to unravel the molecular underpinnings of tumorigenesis and progression, the clinical benefits will eventually be reaped.

In a recent retrospective institutional analysis, the prognosis of patients with muscle-invasive bladder cancer improved over time after surgical intervention. Indeed, duration of survivorship after radical cystectomy was inversely correlated with risk of mortality, suggesting that follow-up regimens should be modelled according to this parameter.

Indocyanine green dye continues to be adopted in robot-assisted surgical procedures; its role has expanded from partial nephrectomy to now include reconstructive procedures. Further studies are required to evaluate whether it is simply an interesting tool in the armamentarium or a technique that can improve patient outcomes.

Bladder cancer recurrence after radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) is a common occurrence. A new nomogram, based on retrospective analysis of a large multicentre cohort, has been shown to predict the risk of intravesical recurrence. Despite limitations, this model could help clinicians to provide personalized postoperative management.

Patients treated with two or more courses of BCG for high-risk non-muscle-invasive bladder cancer are at increased risk of second-site primary tumours of the upper urinary tract and prostatic urethra. A new study highlights the importance of looking for urothelial cancer in extravesical disease sites.

In surgical procedures, there is a delicate balance between preventing thromboembolism by maintaining thromboprophylaxis, and avoiding excessive bleeding. Patients requiring treatment for urinary stones are often taking antithrombotic medication, or have an underlying bleeding disorder. This Review brings together the current recommendations for perioperative management of thromboprophylaxis in lithotripsy.

Hampson et al. discuss the epidemiology, pathogenesis, aetiology, and evaluation of anterior male urethral strictures. They also consider some current controversies in urethroplasty, such as the management of failed hypospadias repair and long or complex strictures, as well as the use of dorsal versus ventral onlay grafting.

2013 saw the publication of several reports providing insight into a range of ongoing issues in bladder cancer, from screening high-risk candidates to using blue-light cystoscopy to reduce recurrence. These data will strengthen efforts to optimize the detection and treatment of bladder cancer, benefiting patients along the cancer continuum.

In the quest for reduced morbidity from radical treatments, tissue-sparing focal therapies are being developed to treat men with localized prostate cancer. However, which patients are most suitable for these experimental therapies remains unclear. One population-based study suggests that the majority of patients are suitable candidates.

A randomized trial involving 460 women with stress urinary incontinence compared physiotherapy with midurethral-sling surgery. We question whether the results, showing higher rates of improvement and cure for surgery than for physiotherapy, should change best practice and clinical practice guideline recommendations.

Fowler's syndrome is a cause of urinary retention in young women that is characterized by an abnormal electromyography reading from the external urethral sphincter. This Review, describing the aetiology, pathogenesis and management of Fowler's syndrome, will serve as a guide for urologists unfamiliar with this rare clinical problem.

After biochemical recurrence following radical prostatectomy, external beam radiation therapy (EBRT) reduces the risk of prostate-cancer-specific mortality. However, many men with a detectable serum PSA level will never experience clinical progression. New definitions of biochemical recurrence could help to determine the most appropriate candidates and time points for salvage EBRT.

Overcoming male infertility resulting from azoospermia requires the retrieval of viable sperm for use in assisted reproduction. Shin and Turek compare the techniques available for sperm retrieval, and discuss considerations including DNA integrity and the ability to tolerate freezing and thawing of sperm from different anatomical locations.

Evaluating the functional aspects of genetic variation in prostate cancer would advance our understanding of its aetiology and enable population stratification for screening. Eeles et al. provide an overview of the current evidence on the germline genetic variants in prostate cancer development, as well as the association of these variants with clinical outcomes.

A retrospective, single institution study of 450 men with biochemical recurrence after radical prostatectomy included 140 men with androgen deprivation therapy deferred until metastatic disease onset. Metastasis-free survival was an independent predictor of overall survival. This research highlights the need to develop appropriate intermediate end points to expedite prostate cancer treatment.

The International Bladder Cancer Group has proposed a new definition for disease progression in non-muscle-invasive bladder cancer that includes stage and grade progression. Although this definition will inevitably be subject to changes, it can currently be regarded as the gold standard for future trials, publications and protocols.

Although abiraterone can largely be considered a success in castration-resistant prostate cancer (CRPC), some patients still acquire resistance. In this Review, the authors describe the field of CYP17 inhibition for CRPC, of which abiraterone is the prime candidate, and describe ongoing medicinal chemistry and clinical efforts to improve CYP17 inhibition while mitigating adverse effects.

Post-hoc analysis of phase III data of abiraterone in men with castration-resistant prostate cancer showed that survival did not differ according to patient age (≤75 years versus >75 years). Similar analyses of other agents have reported mixed findings. Should patient age be part of decision making?

Any mass discovered in the testicle might be cancerous and, therefore, every effort must be made to characterize the lesion. This Review highlights modern aspects of clinical examination, the modalities for scrotal imaging, and the surgical techniques used for exploring the testis.