Minimally Invasive Treatments for Benign Prostatic Obstruction: A Systematic Review and Network Meta-analysis.

CONTEXT: Minimally invasive surgical therapies for male lower urinary tract symptoms secondary to benign prostatic obstruction were developed to be safer and more tolerable than standard ablative techniques. These treatments have not been compared with each other in a randomised fashion, and for some treatments, there are no trials against a reference technique. OBJECTIVE: To compare the efficacy, safety, and tolerability of water vapour thermal therapy (WVTT), prostatic urethral lift (PUL), prostatic arterial embolisation (PAE), temporary implantable nitinol device (iTIND), transurethral microwave thermotherapy (TUMT), and transurethral resection of the prostate (TURP). EVIDENCE ACQUISITION: A systematic search of MEDLINE/PubMed, Embase, Cochrane Library, and grey literature for randomised controlled trials was performed. Trials meeting the selection criteria were assessed for the risk of bias using the Cochrane RoB2 tool. Treatments were compared, using a network meta-analysis, in terms of outcomes including symptom score, quality of life, maximum urinary flow rate, postvoid residual urine, International Index of Erectile Function (IIEF-5), and scales from the Male Sexual Health Questionnaire. EVIDENCE SYNTHESIS: The search identified 63 trials. Symptoms and quality of life for PAE, PUL, and WVTT appeared similar to those for TURP, whereas TURP was found to have the most clinically significant improvement in flow rate. TUMT was less efficacious than TURP but provided similar results on quality of life. Comparisons of ejaculatory function favoured WVTT and PUL compared with TURP. The relative efficacy of iTIND was less clear because of the risk of bias in the respective trial. CONCLUSIONS: PAE, PUL, and WVTT appear favourable from a risk-benefit perspective despite probably having less efficacy than TURP for objective outcomes. These findings warrant confirmation through long-term randomised controlled trials. PATIENT SUMMARY: This paper has summarised the evidence from 63 clinical trials on minimally invasive surgical therapies for men with symptoms of an enlarged prostate, including water vapour thermal therapy (WVTT), prostatic urethral lift (PUL), prostatic arterial embolisation (PAE), temporary implantable nitinol device, and transurethral microwave thermotherapy (TUMT). Improvement in symptoms for each of PAE, PUL, TUMT, and WVTT in short-term follow-up was similar to that for the standard surgical treatment, although standard surgery appeared to provide the greatest increase in urine flow. Men who had WVTT or PUL were less likely to have problems with sexual function than those who had standard surgery.

The Efficacy and Safety of Laser and Electrosurgical Transurethral Procedures for the Treatment of BPO in High-Risk Patients: A Systematic Review.

Objective: To compare efficacy and safety outcomes of GreenLight, Holmium and Thulium laser  techniques with standard monopolar and bipolar transurethral resection of the prostate (TURP) in high-risk patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). Methods: We conducted a systematic literature review of studies in patients undergoing BPO surgeries who may be considered high-risk for standard TURP, with higher risk defined as follows: large prostates (≥80 mL) and/or taking antithrombotic agents and/or urinary retention and/or age >80 years and/or significant comorbidity.  Outcomes summarised included bleeding complications, re-intervention rates, hospital length of stay, and standard measures of disease and symptom severity for all available timepoints. Results: A total of 276 studies of 32,722 patients reported relevant data. Studies were heterogeneous in methodology, population and outcomes reported. IPSS reduction, Qmax improvement and PVR were similar across all interventions. Mean values at baseline and after 12 months across interventions were 13.2-29 falling to 2.3-10.8 for IPSS, 0-19 mL/s increasing to 7.5-34.1 mL/s for Qmax and 41.4-954 mL falling to 5.1-138.3 mL for PVR. Laser treatments show some advantages compared with monopolar and bipolar TURP for some adverse events and safety parameters such as bleeding complications. Duration of hospital stay, reinterventions and recatheterisations were lower with GreenLight, HoLEP, Thulium lasers, and bipolar enucleation than TURP. Conclusions: Laser therapies are effective and well-tolerated treatment options in high-risk patients with BPO compared with monopolar or bipolar TURP. The advantageous safety profile of laser treatments means that patients with a higher bleeding risk should be offered laser surgery preferentially to mTURP or bTURP.

Importance of red patches diagnosed in cystoscopy for haematuria and lower urinary tract symptoms.

BACKGROUND: Biopsy of the red patches in the bladder, when found at cystoscopy, is routinely performed in urological practice. This is done to establish the sinister diagnosis of carcinoma-in-situ among other causes. OBJECTIVE: To analyse the pathology of the red patches and to determine if routine biopsy of these patches is warranted. PATIENTS AND METHODS: This was a retrospective study conducted over a period of 36 months, in which 50 patients were identified, who underwent biopsies of their red patches. All patients with a history of bladder carcinoma and obvious bladder tumours were excluded from this study. RESULTS: The mean age of the patients was 60.8 years. 25 patients had cystoscopy for lower urinary tract symptoms, 21 for haematuria and 4 for recurrent urinary tract infection. Carcinoma in situ was found in 4 (8%) patients, of whom only 2 had positive urine cytology. CONCLUSION: It is prudent to perform a biopsy of all incidentally diagnosed red patches because of a major yield rate of carcinoma in situ. This procedure also picks up other important pathologies, which help in further management.

Missing channels in two-colour microarray experiments: combining single-channel and two-channel data.

BACKGROUND: There are mechanisms, notably ozone degradation, that can damage a single channel of two-channel microarray experiments. Resulting analyses therefore often choose between the unacceptable inclusion of poor quality data or the unpalatable exclusion of some (possibly a lot of) good quality data along with the bad. Two such approaches would be a single channel analysis using some of the data from all of the arrays, and an analysis of all of the data, but only from unaffected arrays. In this paper we examine a 'combined' approach to the analysis of such affected experiments that uses all of the unaffected data. RESULTS: A simulation experiment shows that while a single channel analysis performs relatively well when the majority of arrays are affected, and excluding affected arrays performs relatively well when few arrays are affected (as would be expected in both cases), the combined approach out-performs both. There are benefits to actively estimating the key-parameter of the approach, but whether these compensate for the increased computational cost and complexity over just setting that parameter to take a fixed value is not clear. Inclusion of ozone-affected data results in poor performance, with a clear spatial effect in the damage being apparent. CONCLUSION: There is no need to exclude unaffected data in order to remove those which are damaged. The combined approach discussed here is shown to out-perform more usual approaches, although it seems that if the damage is limited to very few arrays, or extends to very nearly all, then the benefits will be limited. In other circumstances though, large improvements in performance can be achieved by adopting such an approach.

A role for neurotensin in bicalutamide resistant prostate cancer cells.

BACKGROUND: Anti-androgens are administered as a principal treatment for prostate cancer. Aggressive hormone refractory disease is characterized in some cases by the development of a neuroendocrine phenotype. However little attention has been paid to resistance pathways selected for by long-term treatment with non-steroidal anti-androgens. METHODS: Using a resistant sub-line, LNCaP-Bic, we performed a comparative gene expression profiling using cDNA microarrays and target validation by qRT-PCR. Targets were then explored using cell proliferation, cell cycle analysis and in vitro invasion assays using siRNA technology. RESULTS: Neurotensin/Neuromedin N (NTS) was upregulated in the LNCaP-Bic line at both the transcript and protein level. The resistant line was found to have an increased proliferation rate, more rapid cell cycle progression and increased invasiveness through Matrigel. Each phenotypic difference could be reduced using siRNA knockdown of NT. CONCLUSION: Increased expression of NT in bicalutamide resistant prostate cancer cells induces cell proliferation and invasion suggesting that this peptide may contribute to the development of bicalutamide resistant prostate cancer.

Endoscopic management of renal candidiasis.

Renal candidial infections have been described in the literature in susceptible populations of all age groups. Systemic antifungal agents have been successful in treating these patients, but in the presence of an obstructed kidney, antegrade (perurethral) or retrograde (percutaneous) drainage of the pelvicaliceal system is mandatory to salvage the kidney. An aggressive percutaneous endoscopic approach for the management of such a case in a young diabetic patient with multiple comorbidities is described here with initial success.