Evaluation of Outcomes Following Focal Ablative Therapy for Treatment of Localized Clinically Significant Prostate Cancer in Patients >70 Years: A Multi-institute, Multi-energy 15-Year Experience.

PURPOSE: In older patients who do not wish to undergo watchful waiting, focal therapy could be an alternative to the more morbid radical treatment. We evaluated the role of focal therapy in patients 70 years and older as an alternative management modality. MATERIALS AND METHODS: A total of 649 patients across 11 UK sites receiving focal high-intensity focused ultrasound or cryotherapy between June 2006 and July 2020 reported within the UK-based HEAT (HIFU Evaluation and Assessment of Treatment) and ICE (International Cryotherapy Evaluation) registries were evaluated. Primary outcome was failure-free survival, defined by need for more than 1 focal reablation, progression to radical treatment, development of metastases, need for systemic treatment, or prostate cancer-specific death. This was compared to the failure-free survival in patients undergoing radical treatment via a propensity score weighted analysis. RESULTS: Median age was 74 years (IQR: 72, 77) and median follow-up 24 months (IQR: 12, 41). Sixty percent had intermediate-risk disease and 35% high-risk disease. A total of 113 patients (17%) required further treatment. Sixteen had radical treatment and 44 required systemic treatment. Failure-free survival was 82% (95% CI: 76%-87%) at 5 years. Comparing patients who had radical therapy to those who had focal therapy, 5-year failure-free survival was 96% (95% CI: 93%-100%) and 82% (95% CI: 75%-91%) respectively (P < .001). Ninety-three percent of those in the radical treatment arm had received radiotherapy as their primary treatment with its associated use of androgen deprivation therapy, thereby leading to potential overestimation of treatment success in the radical treatment arm, especially given the similar metastases-free and overall survival rates seen. CONCLUSIONS: We propose focal therapy to be an effective management option for the older or comorbid patient who is unsuitable for or not willing to undergo radical treatment.

Bladder infusion versus standard catheter removal for trial of void: a systematic review and meta-analysis.

PURPOSE: To compare the efficacy and time-to-discharge of two methods of trial of void (TOV): bladder infusion versus standard catheter removal. METHODS: Electronic searches for randomized controlled trials (RCTs) comparing bladder infusion versus standard catheter removal were performed using multiple electronic databases from dates of inception to June 2020. Participants underwent TOV after acute urinary retention or postoperatively after intraoperative indwelling catheter (IDC) placement. Quality assessment and meta-analyses were performed, with odds ratio and mean time difference used as the outcome measures. RESULTS: Eight studies, comprising 977 patients, were included in the final analysis. Pooled meta-analysis demonstrated that successful TOV was significantly higher in the bladder infusion group compared to standard TOV (OR 2.41, 95% CI 1.53-3.8, p = 0.0005), without significant heterogeneity (I2=19%). The bladder infusion group had a significantly shorter time-to-decision in comparison to standard TOV (weighted mean difference (WMD)-148.96 min, 95% CI - 242.29, - 55.63, p = 0.002) and shorter time-to-discharge (WMD - 89.68 min, 95% CI - 160.55, - 18.88, p = 0.01). There was no significant difference in complication rates between the two groups. CONCLUSION: The bladder infusion technique of TOV may be associated with a significantly increased likelihood of successful TOV and reduced time to discharge compared to standard TOV practices.

Mid-term outcomes of a male retro-urethral, transobturator synthetic sling for treatment of post-prostatectomy incontinence: Impact of radiotherapy and storage dysfunction.

PURPOSE: To determine mid-term durability of the AdVance sling for post-prostatectomy incontinence (PPI) and impact of prior radiotherapy and storage dysfunction. METHOD: Eighty men undergoing AdVance sling for PPI during 2008-2013 were reviewed. Pre-op urodynamics, pre and post-op pad usage, prior radiotherapy, and PGI-I scores were recorded. RESULT: Mean follow-up was 36 months (range 14-72). Twelve men had radiotherapy pre-op, 10 had detrusor overactivity (DO), and 20 reduced compliance. Pre-op mean 24-hr pad weight was 264 g and mean pads-per-day (PPD) 2.60 ± 0.29. In the early post-op period (3-6 months), mean PPD was 0.40 (SD 0.16); at mid-term follow-up mean PPD was 1.02 ± 0.31. Radiotherapy and DO were independently predictive of poor mid-term outcome. Men with DO or radiotherapy were using 1.03 ± 0.42 (P = 0.019) and 1.17 ± 0.41 (P = 0.02) more PPD, respectively than men without these factors. At mid-term follow-up, men without radiotherapy or DO were using 1.98 ± 0.28 less PPD compared to pre-operatively (P < 0.0001); with radiotherapy or DO men were using 0.73 ± 0.38 (P = 0.057) and 0.72 ± 0.43 (P = 0.092) less PPD, respectively. PGI-I score for men without radiotherapy or DO was 1.98 ± 0.40 ("much better"); with radiotherapy or DO PGI-I score was 3.80 ± 0.49 ("no difference"). CONCLUSION: The AdVance sling provides mid-term improvement in men with PPI. However, men with radiotherapy or DO have significantly poorer outcomes with mid-term results indicating a return to baseline degree of incontinence. Caution should be taken when considering the AdVance sling in these men. Pre-op urodynamics in men with radiotherapy and/or overactive bladder may be important when considering men for AdVance sling. Neurourol. Urodynam. 36:1147-1150, 2017. © 2016 Wiley Periodicals, Inc.

Botulinum toxin (OnabotulinumtoxinA) in the male non-neurogenic overactive bladder: clinical and quality of life outcomes.

OBJECTIVE: To assess the efficacy of OnabotulinumtoxinA (BTXA) injections in men with drug-refractory non-neurogenic overactive bladder (NNOAB). PATIENTS AND METHODS: A total of 43 men received BTXA injections for NNOAB from 2004 to 2012. Patient Global Impression of Improvement (PGI-I) score was obtained. For men with wet NNOAB, change in number of pads per day was also assessed. RESULTS: Forty-three men with a mean age of 69 (range 37-85) received at least one injection. Of the 43 men, 20 (47%) had prior prostate surgery: 11 had radical prostatectomy (RP) and nine had transurethral resection of prostate (TURP). Overall, average PGI-I score was 2.7. Comparing PGI-I score in men who had prior prostate surgery with men who have not: 2.6 ± 0.5 vs 2.8 ± 0.5 respectively (average ± 95% CI), P = 0.6. Comparing PGI-I score in men who had previous TURP with men who had previous RP: PGI-I score: 3.3 ± 0.8 vs 2.0 ± 0.5 respectively, P < 0.05. Men who had RP experienced a reduction in pad use (from 3.5 ± 1.7 to 1.6 ± 0.9 pads/day, P < 0.05) while this was not the case amongst men who had TURP (from 1.7 ± 1.5 to 1.4 ± 1.5 pads/day, P = 0.4). CONCLUSION: Overall, BTXA injection in men with drug-refractory NNOAB does provide a symptomatic benefit. Amongst men who have had prior prostate surgery, men who have had RP experience a greater benefit than men who have had TURP, both in regards to PGI-I score and pad use.

Indwelling urinary catheters: pattern of use in a public tertiary-level Australian hospital.

An audit of charts from patients identified as having an indwelling urinary catheter (IDC) was conducted in a 450-bed, tertiary level hospital (Concord Repatriation General Hospital) in Australia. Documentation of relevant information regarding IDC in the medical record included indication for catheterization, insertion and removal dates, use of antibiotics, place of insertion, designation of inserter, catheter type, availability of IDC kits, and use of catheter fixation devices.

Spontaneous bleeding from an unusual renal mass: A case of gestational choriocarcinoma related to previous pregnancy over a decade earlier.

Gestational choriocarcinoma is an uncommon trophoblastic malignancy, occurring in females after pregnancy, which is rarely encountered by urologists. It can be rapidly progressive, however metastases to other organs can occur after a prolonged latency period. We describe a rare case of solitary metastatic gestational choriocarcinoma presenting with spontaneous bleeding from a renal mass, over a decade after the associated pregnancy with a presumed sub-clinical primary tumour. This case demonstrates the importance of recognising gestational choriocarcinoma as a potential differential diagnosis of spontaneous bleeding renal mass in females of child-bearing age as a urologist given the often-aggressive nature of the disease.

Impact of dual energy characterization of urinary calculus on management.

INTRODUCTION: Dual energy CT (DECT) is a recent technique that is increasingly being used to differentiate between calcium and uric acid urinary tract calculi. The aim of this study is to determine if urinary calculi composition analysis determined by DECT scanning results in a change of patient management. METHOD: All patients presenting with symptoms of renal colic, who had not previously undergone DECT scanning underwent DECT KUB. DECT data of all patients between September 2013 and July 2015 were reviewed. Urinary calculi composition based on dual energy characterization was cross-matched with patient management and outcome. RESULTS: A total of 585 DECT KUB were performed. 393/585 (67%) DECT scans revealed urinary tract calculi. After excluding those with isolated bladder or small asymptomatic renal stones, 303 patients were found to have symptomatic stone(s) as an explanation for their presentation. Of these 303 patients, there were 273 (90.1%) calcium calculi, 19 (6.3%) uric acid calculi and 11 (3.4%) mixed calculi. Of those with uric acid calculi, 15 were commenced on dissolution therapy. Twelve of those commenced on dissolution therapy had a successful outcome, avoiding need for surgical intervention (lithotripsy or stone retrieval). Three patients failed dissolution therapy and required operative intervention for definitive management of the stone. CONCLUSION: Predicting urinary tract calculi composition by DECT plays an important role in identifying patients who may be managed with dissolution therapy. Identification of uric acid stone composition altered management in 15 of 303 (5.0%) patients, and was successful in 12, thereby avoiding surgery and its attendant risks.

Eight-Year Experience With Botulinum Toxin Type-A Injections for the Treatment of Nonneurogenic Overactive Bladder: Are Repeated Injections Worthwhile?

PURPOSE: To investigate the efficacy and safety of repeated botulinum toxin type-A (BTX-A) injections for patients with drug-refractory nonneurogenic overactive bladder (NNOAB) and explore factors predictive of outcome. METHODS: Data were collected from all patients receiving repeated BTX-A injections for drug-refractory NNOAB between 2004 and 2012. Trigone-sparing injections were administered under sedation with antibiotic prophylaxis. Patient characteristics including age, sex, preoperative urodynamics, injection number, BTX-A dose, complications, and patient global impression of improvement (PGI-I) scores were collected. Correlations between patient factors and outcomes were assessed by using Pearson's chi-square tests. RESULTS: Fifty-two patients with a mean age of 67.4 years (range, 26-93 years) received 140 BTX-A injections in total; 33 (64%), 15 (29%), and 4 patients (7%) received 2, 3 to 4, and 5 to 8 injections, respectively. Mean follow-up time was 49 months (range, 9-101 months). Nine patients developed urinary tract infection; additionally, 3 patients experienced transient urinary retention. Median PGI-I score was 2 out of 7 (interquartile range [IQR], 2). For 46 patients, the PGI-I score remained stable with the administration of each injection. Pearson chi-square tests revealed that male patients or reduced bladder compliance was associated with a higher (worse) PGI-I score. Median PGI-I scores for men and women were 3 (IQR, 1) and 2 (IQR, 1), respectively; additionally, median PGI-I scores for those with normal bladder compliance and those with reduced bladder compliance were 2 (IQR, 2) and 4.5 (IQR, 1), respectively. Median PGI-I scores and complication rates were the same in the older patient (≥70 years) and younger (<70 years) patient cohorts. CONCLUSIONS: Efficacy is maintained with repeated BTX-A injections. Patients including the elderly show a good degree of tolerability with a low complication rate. Male patients or reduced bladder compliance is associated with poorer outcomes.