Active surveillance should not be routinely considered in ISUP grade group 2 prostate cancer.

Active surveillance has been proposed as a therapeutic option in selected intermediate risk patients with biopsy grade group 2 prostate cancer. However, its oncologic safety in this setting is debated. Therefore, we conducted a non-systematic literature research of contemporary surveillance protocols including patients with grade group 2 disease to collect the most recent evidence in this setting. Although no randomized controlled trial compared curative-intent treatments, namely radical prostatectomy and radiotherapy vs. active surveillance in patients with grade group 2 disease, surgery is associated with a benefit in terms of disease control and survival when compared to expectant management in the intermediate risk setting. Patients with grade group 2 on active surveillance were at higher risk of disease progression and treatment compared to their grade group 1 counterparts. Up to 50% of those patients were eventually treated at 5 years, and the metastases-free survival rate was as low as 85% at 15-years. When considering low- and intermediate risk patients treated with radical prostatectomy, grade group 2 was one of the strongest predictors of grade upgrading and adverse features. Available data is insufficient to support the oncologic safety of active surveillance in all men with grade group 2 prostate cancer. Therefore, those patients should be counselled regarding the oncologic efficacy of upfront active treatment modalities and the lack of robust long-term data supporting the safety of active surveillance in this setting.

Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment.

AIMS: Sacral neuromodulation (SNM) is a well-established treatment modality for refractory overactive bladder (OAB). There is a paucity of evidence examining the use of SNM in patients who have received prior intravesical onabotulinumtoxinA (BTXA) treatment. We aim to review those patients who underwent SNM for refractory OAB following treatment with BTXA. METHODS: A retrospective review was conducted to identify patients who had undergone prior intradetrusor BTXA for refractory OAB, then subsequent first-stage SNM. Patient demographics, number/dosage of BTXA, voiding diaries, and patient global impression of improvement (PGI-I) scores were recorded. Successful first-stage SNM was defined as subjective patient improvement of greater than 50%. Patient satisfaction and device use at last follow-up was noted. RESULTS: Eighty-three patients were identified having undergone SNM for OAB, of which 36 had prior BTXA treatment and were included in the series. 23/36 (63.9%) of patients had successful first-stage SNM, and underwent insertion of implantable pulse generator, compared to 33/47 (70.2%) in those who had never been treated with BTXA (P = 0.5). Mean PGI-I score was 2.6 (range 1-4). With a mean follow up of 29.1 months (range 12-53), 17/23 (73.9%) were satisfied, and using the device at last follow-up. CONCLUSION: SNM is a suitable treatment option in those patients who have had prior BTXA treatment for refractory OAB, even in those for whom BTXA proved ineffective. Success rates were within the published range, and comparable to our own results, for SNM in OAB patients without prior BTXA treatment.

Should we routinely stent after ureteropyeloscopy?

Arguments 'for' and 'against' ureteric stenting after ureteropyeloscopy are discussed. An individualised approach balancing renal function preservation, irritative lower urinary tract symptoms and emergent return to theatre needs to be adopted while being mindful of healthcare spending.

BCG induced lower urinary tract symptoms during treatment for NMIBC-Mechanisms and management strategies.

Non-muscle invasive bladder cancer (NMIBC) accounts for ~70-75% of total bladder cancer tumors and requires effective early intervention to avert progression. The cornerstone of high-risk NMIBC treatment involves trans-urethral resection of the tumor followed by intravesical Bacillus Calmette-Guerin (BCG) immunotherapy. However, BCG therapy is commonly accompanied by significant lower urinary tract symptoms (LUTS) including urinary urgency, urinary frequency, dysuria, and pelvic pain which can undermine treatment adherence and clinical outcomes. Despite this burden, the mechanisms underlying the development of BCG-induced LUTS have yet to be characterized. This review provides a unique perspective on the mechanisms thought to be responsible for the development of BCG-induced LUTS by focussing on the sensory nerves responsible for bladder sensory transduction. This review focuses on how the physiological response to BCG, including inflammation, urothelial permeability, and direct interactions between BCG and sensory nerves could drive bladder afferent sensitization leading to the development of LUTS. Additionally, this review provides an up-to-date summary of the latest clinical data exploring interventions to relieve BCG-induced LUTS, including therapeutic targeting of bladder contractions, inflammation, increased bladder permeability, and direct inhibition of bladder sensory signaling. Addressing the clinical burden of BCG-induced LUTS holds significant potential to enhance patient quality of life, treatment compliance, and overall outcomes in NMIBC management. However, the lack of knowledge on the pathophysiological mechanisms that drive BCG-induced LUTS has limited the development of novel and efficacious therapeutic options. Further research is urgently required to unravel the mechanisms that drive BCG-induced LUTS.

The autologous pubovaginal fascial sling: An update in 2019.

The contemporary management of stress urinary incontinence (SUI) has seen renewed interest in the use of autologous fascia for the formation of a retropubic suburethral sling. Traditionally, it has been used in only the most severe of incontinence cases, such as those women with intrinsic sphincter deficiency, or in patients requiring concomitant reconstructive procedures. In the current climate surrounding transvaginal mesh, many doctors and patients are shying away from the less morbid synthetic midurethral sling. International literature has demonstrated that the fascial sling is a safe and efficacious procedure for all patients with SUI, adequately treating both urethral hypermobility and intrinsic sphincter deficiency. This paper will discuss the indications, technique, and outcomes of autologous fascial slings. We will explore the use of fascial slings following failed synthetic slings and also the troubleshooting of commonly encountered issues intra- and postoperatively.

Transperitoneal Robot-Assisted Radical Prostatectomy Should Be Considered in Prostate Cancer Patients with Pelvic Kidneys.

We highlight two cases of transperitoneal robot-assisted radical prostatectomy (RARP) in patients with pelvic kidneys because of congenital development and renal transplant. These uncommon cases present a challenge to the surgeon contemplating surgery because of access and anomalous vascular and ureteral anatomy. We describe the technical considerations that are paramount in effectively completing transperitoneal RARP, and believe it should be considered as a treatment option in men with pelvic kidneys.