HoLEPs: A Comparative Study of Men With Massive Prostate Volumes ≥150 mL and <150 mL.

OBJECTIVE: To assess outcomes following Holmium Laser Enucleation of Prostate (HoLEP) in men with prostate volumes ≥150cc and compare this to men with prostate volumes ≤150 cc. PATIENTS & METHODS: We analyzed our prospective database of consecutive patients undergoing HoLEP in a single tertiary public hospital between October 2016 and January 2019. We excluded patients with clinically significant prostate cancer or neurogenic bladders. Preoperative prostate volume was measured on MRI or ultrasonography. Perioperative variables and functional outcomes were recorded. RESULTS: Of 304 HoLEPs performed, we included 97 patients with prostate volume of ≥150 cc and 186 patients with prostate volume <150 cc. Comparing both cohorts (≥150 cc vs <150 cc): mean age was 71.5 vs 68.3 years, prostate volume 195 cc vs 93 cc, preoperative Qmax 9.6mL/s vs 10mL/s, American Urology Association Symptom Score (IPSS) 21 points vs 20.5 points; mean PSA 13.2µg/L vs 8.8µg/L; laser duration 86 vs 59 minutes; morcellation duration 29 vs 14 minutes; enucleated weight was 124 g vs 60 g. One patient (1%) from the ≥150 cc cohort required a surgical procedure for stress urinary incontinence, and none from the <150 cc cohort, but this did not achieve statistical significance (P = .12). There were no statistically significant differences in postoperative Qmax (32.3 vs 26.4 mL/s; P = .12), IPSS (5.9 points vs 7.3points; P = .23), mean PSA (3.9 µg/L vs 2.2 µg/L; P = .60), stricture incidence (1% vs 2.7%; P = .63), or significant stress urinary incontinence (4.1% vs 0.5%; P = .08). CONCLUSION: Our large series demonstrates that HoLEP is safe and effective in patients with massive prostates (≥150 cc), with similar outcomes compared to patients with prostates <150 cc.

EXIT from TRansrectal prostate biopsies (TREXIT): sepsis rates of transrectal biopsy with rectal swab culture guided antimicrobials versus freehand transperineal biopsy.

BACKGROUND: Transrectal prostate biopsy (TRUSBx) holds a risk of prostate biopsy related sepsis. We discuss our step-wise strategies aiming to reduce this risk, including targeted antimicrobials and switching to a freehand transperineal approach (FHTPBx). SUBJECTS AND METHODS: This longitudinal cohort study included three groups. Group A underwent TRUSBx with empirical augmented antimicrobial prophylaxis; Group B underwent TRUSBx with targeted antimicrobial prophylaxis, based on rectal-swab cultures/sensitivity; Group C underwent FHTPBx with empirical antimicrobial prophylaxis. Post biopsy sepsis, defined according to the surviving sepsis campaign and confirmed with blood or urinary cultures, were determined and rates between groups were analysed using fisher's exact test. RESULTS: Of all 1501 patients, 23 developed post biopsy sepsis; Group A (12/609, 2.0%), B (9/403, 2.2%), C (2/489, 0.4%). Targeted antimicrobials did not reduce the risk of post biopsy sepsis following TRUSBx (A vs B, 2.0% vs 2.2%; p = 0.82). Patients with antimicrobial-resistant rectal flora had an increased post biopsy sepsis rate following TRUSBx despite targeted antimicrobials (9.1% vs 1.1%, p = 0.003). Switching to FHTPBx reduced the risk of developing post biopsy sepsis (A vs C, 2% vs 0.4%, p = 0.03; B vs C, 2.2% vs 0.4%, p = 0.03). CONCLUSIONS: Targeted antimicrobials based on rectal swab culture failed to reduce the overall risk of post biopsy sepsis, while FHTPBx nearly eliminated this risk. We recommend the use of transperineal prostate biopsies for all patients as the most effective method to reduce the risk of sepsis.

Continuity of Cancer Care: The Surgical Experience of Two Large Cancer Hubs in London and Milan.

The SARS-CoV-2 (COVID-19) pandemic is having a large effect on the management of cancer patients. This study reports on the approach and outcomes of cancer patients receiving radical surgery with curative intent between March and September 2020 (in comparison to 2019) in the European Institute of Oncology, IRCCS (IEO) in Milan and the South East London Cancer Alliance (SELCA). Both institutions implemented a COVID-19 minimal pathway where patients were required to self-isolate prior to admission and were swabbed for COVID-19 within 72 h of surgery. Positive patients had surgery deferred until a negative swab. At IEO, radical surgeries declined by 6% as compared to the same period in 2019 (n = 1477 vs. 1560, respectively). Readmissions were required for 3% (n = 41), and <1% (n = 9) developed COVID-19, of which only one had severe disease and died. At SELCA, radical surgeries declined by 34% (n = 1553 vs. 2336). Readmissions were required for 11% (n = 36), <1% (n = 7) developed COVID-19, and none died from it. Whilst a decline in number of surgeries was observed in both centres, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.

Safety of "hot" and "cold" site admissions within a high-volume urology department in the United Kingdom at the peak of the COVID-19 pandemic.

OBJECTIVES: To determine the safety of urological admissions and procedures during the height of the COVID-19 pandemic using "hot" and "cold" sites. The secondary objective is to determine risk factors of contracting COVID-19 within our cohort. PATIENTS AND METHODS: A retrospective cohort study of all consecutive patients admitted from March 1 to May 31, 2020 at a high-volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a "cold" site requiring a negative COVID-19 swab 72-hours prior to admission and patients were required to self-isolate for 14-days preoperatively, while all acute admissions were admitted to the "hot" site.Complications related to COVID-19 were presented as percentages. Risk factors for developing COVID-19 infection were determined using multivariate logistic regression analysis. RESULTS: A total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44-70) were admitted under the urology team; 101 (16.5%) on the "cold" site and 510 (83.5%) on the "hot" site. Procedures were performed in 495 patients of which eight (1.6%) contracted COVID-19 postoperatively with one (0.2%) postoperative mortality due to COVID-19. Overall, COVID-19 was detected in 20 (3.3%) patients with two (0.3%) deaths. Length of stay was associated with contracting COVID-19 in our cohort (OR 1.25, 95% CI 1.13-1.39). CONCLUSIONS: Continuation of urological procedures using "hot" and "cold" sites throughout the COVID-19 pandemic was safe practice, although the risk of COVID-19 remained and is underlined by a postoperative mortality.

Effect of Augmented Antimicrobial Prophylaxis and Rectal Swab Culture-guided Targeted Prophylaxis on the Risk of Sepsis Following Transrectal Prostate Biopsy.

BACKGROUND: Sepsis is a severe complication following transrectal ultrasound-guided prostate biopsy (TRUSPBx). Ciprofloxacin is commonly used for prophylaxis; however, there is an increasing incidence of resistant enteric organisms worldwide. OBJECTIVE: To investigate the effect of a targeted prophylactic antimicrobial regimen based on rectal swab cultures in reducing the rate of sepsis. DESIGN, SETTING, AND PARTICIPANTS: A total of 1012 patients were included. Group A (609 patients) received an empirical prophylactic antimicrobial regimen of gentamicin, metronidazole, and ciprofloxacin. Targeted antimicrobial prophylaxis was introduced due to significant ciprofloxacin and gentamicin resistance in patients admitted with sepsis following TRUSPBx. The remaining 403 patients (Group B) had rectal swab cultures performed prior to biopsy. Patients with organisms resistant to ciprofloxacin or gentamicin received a targeted prophylaxis regimen of fosfomycin, amikacin, and metronidazole. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We retrospectively collected and analysed data on sepsis and bacteraemia for all patients as well as data on rectal swab culture, recent foreign travel, and recent antibiotic use for patients in Group B. RESULTS AND LIMITATIONS: In group A, 12 (2.0%) patients developed sepsis following TRUSPBx, while in group B, 9 (2.2%) patients developed sepsis despite targeted prophylaxis (p=0.82). Patients with ciprofloxacin-resistant rectal flora had a significantly higher rate of sepsis (9.1% vs 1.1%; p=0.003). There was a reduction in patients admitted with bacteraemia and severe sepsis between group A (1.2%) and group B (0.3%) which did not reach statistical significance (p=0.16). In group B, 55 of 403 (13.6%) patients had ciprofloxacin-resistant rectal flora, while 66 (16.4%) had organisms resistant to both ciprofloxacin and gentamicin. A recent foreign travel history was associated with an increased incidence of ciprofloxacin-resistant rectal flora (23.6% vs 10.8%; p=0.007). The main limitations of our study include its retrospective nature and potential under-reporting of less severe infectious complications. CONCLUSIONS: Rectal swab cultures identify patients with ciprofloxacin-resistant rectal flora who have an eight-fold risk of sepsis. Targeted antimicrobial prophylaxis may not be beneficial in reducing the sepsis rate when compared with augmented empirical prophylaxis. In an era of increasing antimicrobial resistance, transperineal prostate biopsies should be considered to reduce the risk of infective complications. PATIENT SUMMARY: Performing rectal swab culture prior to transrectal prostate biopsy can help identify patients at risk of developing sepsis despite targeted prophylactic antibiotics.

Vaccines for the prevention of recurrent urinary tract infections: a systematic review.

OBJECTIVES: To systematically review the evidence regarding the efficacy of vaccines or immunostimulants in reducing the recurrence rate of urinary tract infections (UTIs). MATERIALS AND METHODS: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), PubMed, Cochrane Library, World Health Organization (WHO) International Clinical Trials Registry Platform Search Portal, and conference abstracts were searched up to January 2018 for English-titled citations. Randomised placebo-controlled trials evaluating UTI recurrence rates in adult patients with recurrent UTIs treated with a vaccine were selected by two independent reviewers according to the Population, Interventions, Comparators, and Outcomes (PICO) criteria. Differences in recurrence rates in study populations for individual trials were calculated and pooled, and risk ratios (RRs) using random effects models were calculated. Risk of bias was assessed using the Cochrane Collaboration's tool and heterogeneity was assessed using chi-squared and I2 testing. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence (QOE) and summarise findings. RESULTS: In all, 599 records were identified, of which 10 studies were included. A total of 1537 patients were recruited and analysed, on whom data were presented. Three candidate vaccines were studied: Uro-Vaxom® (OM Pharma, Myerlin, Switzerland), Urovac® (Solco Basel Ltd, Basel, Switzerland), and ExPEC4V (GlycoVaxyn AG, Schlieren, Switzerland). At trial endpoint, the use of vaccines appeared to reduce UTI recurrence compared to placebo (RR 0.74, 95% confidence interval [CI] 0.67-0.81; low QOE). Uro-Vaxom showed the greatest reduction in UTI recurrence rate; the maximal effect was seen at 3 months compared with 6 months after initial treatment (RR 0.67, 95% CI 0.57-0.78; and RR 0.78, 95% CI 0.69-0.88, respectively; low QOE). Urovac may also reduce risk of UTI recurrence (RR 0.75, 95% CI 0.63-0.89; low QOE). ExPEC4V does not appear to reduce UTI recurrence compared to placebo at study endpoint (RR 0.82, 95% CI 0.62-1.10; low QOE). Substantial heterogeneity was observed across the included studies (chi-squared = 54.58; P < 0.001, I2  = 84%). CONCLUSIONS: While there is evidence for the efficacy of vaccines in patients with recurrent UTIs, significant heterogeneity amongst these studies renders interpretation and recommendation for routine clinical use difficult at present. Further randomised trials using consistent definitions and endpoints are needed to study the long-term efficacy and safety of vaccines for infection prevention in patients with recurrent UTIs.

Extra-Anatomic Stents in Ureteric Obstruction: Our Experience.

OBJECTIVES: To present our experience of the Detour extra-anatomic stent (EAS; Porges-Coloplast, Denmark) to bypass ureteric obstruction. Use of the EAS is indicated in patients with complex ureteric strictures or malignant disease, where long-term nephrostomy drainage is undesirable. MATERIALS AND METHODS: Between December 2001 and October 2017, 20 Detour EAS were implanted into 13 patients. The primary indication was ureteric obstruction or injury secondary to metastatic malignancy, or from treatment for malignancy. Five patients required bilateral EAS, with two patients having bilateral EAS following initial unilateral insertion. In 11 patients, the stent was inserted into their bladder, with 2 diverted into a double-barreled stoma. The mean age at the time of implantation was 64 years (range: 50-83 years), and the median follow-up was 12 months (range: 1.5-42 months). RESULTS: Four patients required stent revision for urinary leaks, and two developed recurrent urinary tract infections in their stent requiring intravenous antibiotics. All EAS continued to drain successfully following treatment or revision. One patient died due to complications from dislodgement of the stent, leading to laparotomy and intra-abdominal sepsis. Seven patients died due to progression of metastatic malignant disease, and the Detour EAS was functioning in all seven at time of death. The remaining five patients are well with functioning Detour EAS. CONCLUSIONS: The Detour EAS system provides a suitable alternative option for urinary diversion, affording a good quality of life to carefully selected patients with multiple comorbidities and malignant disease.

Testicular Rupture or Testicular Fracture? A Case Report and Literature Review.

Testicular trauma is relatively uncommon. However, severe injuries can result in many complications and should be carefully diagnosed and managed. We present a case of testicular fracture diagnosis made by ultrasonography. The surgical exploration revealed the fracture as well as complete rupture of the tunica albuginea. Testicular rupture is the disruption of the tunica albuginea, while testicular fracture is a "break" in the testicular parenchyma. Management could be conservative in mild fracture cases without rupture while suspected or confirmed fracture should be treated by surgical exploration.

Villous adenoma of the urachal remnant: A diagnostic conundrum.

Villous adenoma is a rare pathology seen in the urinary tract; it is mostly found in the large bowel. When encountered in the urinary tract, it mainly originates from intestinal segments of urinary reconstruction. Villous adenoma is commonly seen in patients more than 50 years and has a male predominance. In the urinary tract, it has been reported in the urachus, bladder dome and trigone. A few cases of villous adenoma have been described in the literature. We report a case of primary villous adenoma in the remnant of the urachus and discuss the pathophysiology, investigation and management.

Spontaneous rupture of a renal artery pseudoaneurysm with no precipitating risk factor.

Renal artery pseudoaneurysm is a rare complication following renal interventional procedures or, although it may be spontaneous as described in this case. Clinicians should have a low threshold for early computer tomography (CT) imaging in cases of diagnostic uncertainty.

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics.

INTRODUCTION AND OBJECTIVES: Stone formers often have a chronic exposure to significant quantities of ionising radiation from radiological investigations and interventions. Predicting radiation exposure would allow the clinician to quantify expected cumulative radiation and find strategies to minimise exposure. We evaluated radiation exposure during ureteroscopy and laser lithotripsy (URS + LL) for a single stone episode and correlated the results to stone characteristics. METHOD: Data was collected retrospectively for all patients undergoing URS + LL in our institution over a 1 year period. Patients with multiple stones, staghorn stones or incomplete stone clearance were excluded to simplify the analysis. Patient characteristics, fluoroscopy data and stone characteristics were recorded. RESULTS: We included 302 consecutive patients in the study. The majority of stones were located in the renal calyces/pelvis (54%) with the rest located in the upper (18%), middle (13%) and lower ureter (15%). Mean stone diameter was 9.9 mm (range 4-30 mm). Mean radiation exposure time during URS + LL was 44 s (range 12-119 s) with a mean total radiation exposure of 7.5 milligray (mGy; range 1.2-29.7 mGy). Renal stones were associated with 27% higher radiation exposure compared to ureteral stones (8.3 vs. 6.7 mGy; p = 0.02). There was a positive correlation between stone diameter and radiation exposure (Spearman's correlation coefficient ρ = 0.28; p < 0.001). Stones with diameter greater than 10 mm were associated with 37% higher radiation exposure compared to smaller stones (9.1 vs. 6.6 mGy; p < 0.001). CONCLUSION: There is a direct correlation between stone burden, as well as location, and radiation exposure during URS + LL. Clinicians should consider strategies to reduce total radiation exposure in recurrent stone formers at risk of high radiation exposure by limiting screening time, using pulsed rather than continuous fluoroscopy, management with primary URS + LL, or using ultrasound guidance.

Managing penetrating renal trauma: experience from two major trauma centres in the UK.

OBJECTIVES: To present our series of patients with penetrating renal trauma treated at two urban major trauma centres and to discuss the contemporary management of such injuries. METHODS: We reviewed prospective urological trauma databases for all patients presenting with penetrating renal trauma between January 2005 and October 2016. Patient demographics, clinical characteristics, imaging, management and follow-up data were analysed. RESULTS: Over the 11-year period, 63 patients presented with penetrating renal injuries. The vast majority of patients were male (n = 61; 96.8%), with a mean (range) age of 27.4 (14-71) years. Injuries were equally common on either side (31 left, 32 right). The most common mechanism of injury was stabbing (n = 55; 87.3%), followed by gunshot (n = 7; 11.1%) and crossbow injuries (n = 1; 1.6%). All patients underwent contrast-enhanced computed tomography. Using the American Association for the Surgery of Trauma renal injury grading system, 11 (17.5%) had grade II, 26 (41.3%) had grade III and 26 (41.3%) had grade IV injury. The most common associated injuries were thoracic (n = 23; 36.5%), liver (n = 11; 17.5%), splenic (n = 10; 15.9%), gastrointestinal tract (n = 8; 12.7%) and musculoskeletal (n = 6; 9.5%). At presentation, 16 patients (25.4%) were haemodynamically unstable. The majority of patients did not require blood transfusion (n = 56; 88.9%), while transfusion of >5 units was rare (n = 4; 6.3%). Fifty-two patients (82.5%) were managed by observation alone, while 10 (15.9%) underwent emergency angiography and embolization. Patients with grade IV injury were more likely to require embolization than those with grade III injury; however, the difference was not significant (26.9% vs 15.4%; P = 0.29). One patient (1.6%) underwent retroperitoneal exploration of their renal injury and was managed conservatively. Eight patients underwent laparotomy for other visceral injuries while their renal injury was managed conservatively. Renal artery pseudoaneurysm developed in five patients (7.9%) and one patient (1.6%) developed renal arteriovenous malformation. No patients underwent nephrectomy and no mortality was reported. CONCLUSIONS: The vast majority of patients with penetrating renal injuries can be safely managed non-operatively in this setting. Selective renal artery embolization is an effective option for patients in an unstable condition, with excellent outcomes. Associated thoracic or visceral injuries requiring operative management are common in penetrating renal trauma, while urologists should limit or have a high threshold for surgical intervention.

Robotic partial nephrectomy for duplex kidney with ectopic ureter draining in the vagina in an adult patient with urinary incontinence.

A duplex kidney system with an ectopic ureter draining into the vagina is a congenital malformation that typically presents as refractory urinary incontinence. Diagnosis is often difficult to establish and delayed due to a low incidence. We present the case of a patient aged 26 years with a life-long history of persistent urinary incontinence. Initial presentation was at childhood; however, the diagnosis went undetermined for 22 years. CT urography revealed a duplex kidney with an atrophic upper pole associated with an ectopic ureter that drained into the vaginal vault. This is the first description of such a case being managed successfully via a robot-assisted partial nephrectomy approach. Ectopic ureteral duplication should be considered in the differential diagnosis for young women with refractory urinary incontinence. Robotic partial nephrectomy is a safe and effective technique to manage such cases.

Urolithiasis following urinary diversion.

Urolithiasis is a well-known occurrence after cystectomy and urinary diversion. With high incidence and recurrence rates of urolithiasis, complex anatomy and associated morbidities, these patients remain a management challenge for urologists. The purpose of this review is to examine the literature and consider the risk factors for stone formation in this group of patients and reflect on the reported outcomes with the range of available treatment options.

Partial vs radical nephrectomy for T1 renal tumours: an analysis from the British Association of Urological Surgeons Nephrectomy Audit.

OBJECTIVES: To analyse and compare data from the British Association of Urological Surgeons Nephrectomy Audit for perioperative outcomes of partial (PN) and radical nephrectomy (RN) for T1 renal tumours. PATIENTS AND METHODS: UK consultants were invited to submit data on all patients undergoing nephrectomy between 1 January and 31 December 2012 to a nationally established database using a standard pro forma. Analysis was made on patient demographics, operative technique, and perioperative data/outcome between PN and RN for T1 tumours. RESULTS: Overall, data from 6 042 nephrectomies were reported of which 1 768 were performed for T1 renal tumours. Of these, 1 082 (61.2%) were RNs and 686 (38.8%) were PNs. The mean age of patients undergoing PN was lower (PN 59 years vs RN 64 years; P < 0.001) and so was the WHO performance score (PN 0.4 vs RN 0.7; P < 0.001). PN for the treatment of T1a tumours (≤4 cm) accounted for 55.6% of procedures, of which 43.9% were performed using a minimally invasive technique. For T1b tumours (4-7 cm), 18.9% of patients underwent PN, in 33.3% of which a minimally invasive technique was adopted. The vast majority of RNs for T1 tumours were performed using a minimally invasive technique (90.3%). Of the laparoscopic PNs, 30.5% were robot-assisted. There was no significant difference in overall intraoperative complications between the RN and PN groups (4% vs 4.3%; P = 0.79). However, PN accounted for a higher overall postoperative complications rate (RN 11.3% vs PN 17.6%; P < 0.001). RN was associated with a markedly reduced risk of severe surgical complications (Clavien Dindo classification grade ≥3) compared with PN even after adjusting for technique (odds ratio 0.30; P = 0.002). Operation time between RN and PN was comparable (141 vs 145 min; P = 0.25). Blood loss was less in the RN group (mean for RN 165 vs PN 323 mL; P < 0.001); however, transfusion rates were similar (3.2% vs 2.6%; P = 0.47). RN was associated with a shorter length of stay (median 4 vs 5 days; P < 0.001). A direct comparison between robot-assisted and laparoscopic PN showed no significant differences in operation time, blood loss, warm ischaemia time, and intraoperative and postoperative complications. CONCLUSIONS: PN was the method of choice for treatment of T1a tumours whereas RN was preferred for T1b tumours. Minimally invasive techniques have been widely adopted for RN but not for PN. Despite the advances in surgical technique, a substantial risk of postoperative complications remains with PN.

Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer.

We describe the case of a 65-year-old man who developed spontaneous bladder rupture after picking up his suitcase from a squatting position. He was known to have non-muscle invasive bladder cancer (NMIBC), managed previously with transurethral resections and intravesical chemotherapy. CT scan showed a large amount of free intraperitoneal fluid anterior to the bladder, suggestive of a urinoma. Management was initially conservative, with insertion of urethral catheter, intravenous antibiotics and fluid resuscitation. Follow-up CT scan showed resolution of the urinoma with the patient making a full recovery after 3 weeks.

Live surgery at conferences - Clinical benefits and ethical dilemmas.

Live surgical broadcasts (LSBs) are becoming increasingly popular in urological conferences. These activities can provide excellent training opportunities, as they allow the audience to view an operation conducted by world-renowned surgeons, and have the ability to interact with them in real time. However, several ethical considerations have been raised with this practice, which the participating surgeons and conference organisers must appreciate and address carefully. In this article we highlight the ethical considerations related to LSBs and advise on how these should be addressed. We also present the latest recommendations made by the European Association of Urology Live Surgery Committee and discuss alternatives to LSB.

Complementary and alternative medicine (CAM) in prostate and bladder cancer.

To provide an overview of the scientific and clinical studies underlying the most common vitamin and herbal preparations used in prostate and bladder cancer and evaluate the evidence behind them. A literature search was undertaken on PubMed using various keywords relating to the use of complementary and alternative medicine (CAM) in prostate and bladder cancer.Vitamin E and selenium supplementation can potentially have adverse effects by increasing the risk of prostate cancer. Initial clinical studies of pomegranate and green tea, investigating their chemotherapeutic properties in prostate and bladder cancer have yielded encouraging results. Curcumin, resveratrol, and silibinin have potential anticancer properties through multiple molecular targets; their clinical effectiveness in prostate and bladder cancer is yet to be evaluated. Zyflamend, like PC-SPES, is a combined CAM therapy used in prostate cancer. Acupuncture is popular among patients experiencing hot flushes who are receiving androgen-deprivation therapy for prostate cancer. Conclusive evidence for the use of CAM in prostate and bladder cancer is lacking and not without risk.

Primary pyomyositis: an unusual presentation in an older patient with no recognised risk factors.

Primary pyomyositis is a subacute deep bacterial infection of skeletal muscle. It is typically seen in tropical countries with Staphylococcus aureus being the commonest pathogen. Immunocompromised states and trauma are associated with cases in temperate climates where there is an increasing incidence, typically in children and young adults. However, the authors present a case of primary pyomyositis in a previously healthy 80-year-old female. The authors highlight the potential difficulties in early diagnosis of this rare condition in the UK indicating the need for early MRI imaging and the low sensitivity of blood cultures and serum creatine kinase measurements. Treatment, including early surgical drainage and appropriate antibiotic therapy, is discussed.