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Urology News

Lab on a chip detects prostate cancer, kidney disease on the spot

MedicalNewsToday - 7 hours 55 min ago
When you flush the toilet, you may be discarding microscopic warning signs about your health.But a cunningly simple new device can stop that vital information from "going to waste.
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Frailty increases kidney transplant recipients' risk of dying prematurely

MedicalNewsToday - 8 hours 55 min ago
Regardless of age, frailty is a strong risk factor for dying prematurely after a kidney transplant.
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Preservation of the Neurovascular Bundles Is Associated with Improved Time to Continence After Radical Prostatectomy But Not Long-term Continence Rates: Results of a Systematic Review and Meta-analysis

Abstract Context

The aetiology of urinary incontinence following radical prostatectomy (RP) is incompletely understood. In particular, it is unclear whether there is a relationship between neurovascular bundle (NVB) sparing and post-RP urinary continence.

Objective

To review systematically the association of NVB sparing in RP with postoperative urinary continence outcomes and synthesise the results in a meta-analysis.

Evidence acquisition

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. PubMed, Medline, and Cochrane Central Register of Controlled Trials were searched (December 2013), yielding 3413 unique records. A total of 27 longitudinal cohort studies were selected for inclusion. Studies were evaluated using a predefined criteria adapted from the Cochrane Tool to Assess Risk of Bias in Cohort Studies.

Evidence synthesis

Data from 13 749 participants in 27 studies were synthesised in a meta-analysis. An assessment of the study methodology revealed a high risk of bias due to differences in baseline characteristics, outcome assessment, and the likely presence of unreported confounding factors such as meticulous apical dissection. Meta-analysis demonstrated that nerve sparing (NS) compared with non–nerve sparing (NNS) resulted in improved early urinary continence rates up to 6 mo postoperatively. Beyond this time, no significant difference was observed. This effect was seen most clearly for bilateral NS compared with NNS. A sensitivity analysis of prospective cohort studies revealed consistent results.

Conclusions

This analysis demonstrates an association between NS and improved urinary continence outcomes up to 6 mo postoperatively. NS in men with poor preoperative erectile function should be considered in the context of oncologic risk stratification because it may improve time to continence recovery. The underlying cause of the relationship between NS and continence is unknown. It may represent preservation of the intrapelvic somatic nerves supplying the rhabdosphincter or the influence of other confounding factors. Future research should be directed towards improving understanding of the anatomy of urinary continence and the pathophysiology of post-RP incontinence.

Patient summary

We found that avoiding damage to the nerves around the prostate improves urinary continence in the first 6 mo after surgery. After this time, there is no difference in continence between men who had these nerves removed and those who had them saved. This finding could be due to a true effect of saving these nerves or to a number of other factors affecting the research.

Take Home Message

There is an association between preservation of the neurovascular bundles in radical prostatectomy and improved urinary continence rates up to 6 mo postoperatively. The underlying cause of this relationship is unknown.

Keywords: Radical prostatectomy, Prostate cancer, Nerve sparing, Incontinence.

Footnotes

a Departments of Urology and Surgery, Royal Melbourne Hospital and the University of Melbourne, Melbourne, Australia

b Epworth Prostate Centre, Epworth Healthcare, Melbourne, Australia

c Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia

d Department of Urology, Frankston Hospital, Melbourne, Australia

Corresponding author. Department of Urology, Royal Melbourne Hospital, Level 3 Centre, Grattan Street, Parkville, Victoria 3050, Australia. Tel. +61 39342 7294; Fax: +61 39342 8928.

Article information

PII: S0302-2838(14)01034-3
DOI: 10.1016/j.eururo.2014.10.020
© 2014 Published by Elsevier B.V.

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The Evolving Picture of Lower Urinary Tract Symptom Management

Refers to article:

Long-term Safety and Efficacy of Single-tablet Combinations of Solifenacin and Tamsulosin Oral Controlled Absorption System in Men with Storage and Voiding Lower Urinary Tract Symptoms: Results from the NEPTUNE Study and NEPTUNE II Open-label Extension

Marcus J. Drake, Christopher Chapple, Roman Sokol, Matthias Oelke, Klaudia Traudtner, Monique Klaver, Ted Drogendijk and Philip Van Kerrebroeck on behalf of the NEPTUNE Study Group.

Accepted 14 July 2014

Footnotes

a La Sapienza University, Rome, Italy

b Sant’Andrea Hospital, Rome, Italy

Corresponding author. Department of Urology, La Sapienza University, Sant’Andrea Hospital, Via di Grottarossa, 1035, Rome, 00189, Italy. Tel. +39 06 3377 7712; Fax: +39 06 3377 5049.

Article information

PII: S0302-2838(14)01024-0
DOI: 10.1016/j.eururo.2014.10.016
© 2014 Published by Elsevier B.V.

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Reporting Geographic and Temporal Trends in Renal Cell Carcinoma: Why Is This Important?

Refers to article:

International Variations and Trends in Renal Cell Carcinoma Incidence and Mortality

Ariana Znaor, Joannie Lortet-Tieulent, Mathieu Laversanne, Ahmedin Jemal and Freddie Bray

Accepted 1 October 2014

Footnotes

Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

Corresponding author. Department of Urology, University of Texas MD Anderson Cancer Center, Dan L. Duncan Building (CPB7.3273), 1515 Holcombe Blvd., Unit 1373, Houston, TX 77030, USA. Tel. +1 713 792 3250.

Article information

PII: S0302-2838(14)01118-X
DOI: 10.1016/j.eururo.2014.10.030
© 2014 Published by Elsevier B.V.

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Updated guideline recommends not using PSA test for prostate cancer

MedicalNewsToday - Wed, 2014-10-29 02:00
A new Canadian guideline recommends that the prostate-specific antigen (PSA) test should not be used to screen for prostate cancer based on evidence that shows an increased risk of harm and uncertain...
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Editorial Comment

Urology (Gold Journal) In Press - Wed, 2014-10-29 00:00
The authors provide retrospective data on flexible ureterorenoscopy (f-URS) in a large cohort of patients, and divide patients into groups based on their body mass index. The authors do not describe their overall selection criteria for patients to undergo f-URS rather than percutaneous nephrolithotomy (PCNL) or shock wave lithotripsy, nor how many patients underwent these other procedures during the same interval.
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Comparative Study of the Treatment of Renal Stones With Flexible Ureterorenoscopy in Normal Weight, Obese, and Morbidly Obese Patients

Urology (Gold Journal) In Press - Wed, 2014-10-29 00:00
To compare the efficacy and the safety of flexible ureterorenoscopy (f-URS) in the treatment of kidney stones according to the body mass index (BMI), which seems to be less influenced by weight compared with shock wave lithotripsy and percutaneous nephrolithotomy.
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Equivocal Ureteropelvic Junction Obstruction On Diuretic Renogram: Should Minimally Invasive Pyeloplasty Be Offered In Symptomatic Patients?

Equivocal uretero-pelvic junction obstruction (EqUPJO) refers to patients with clinical symptoms and/or other radiologic suggestion of possible UPJO, but with inconclusive results of obstruction on a diuretic renogram (DRG). We herein evaluate long-term outcomes of patients with EqUPJO who have undergone minimally invasive pyeloplasty (MIP).
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Patterns of Declining Use and the Adverse Effect of Primary Androgen Deprivation on All-cause Mortality in Elderly Men with Prostate Cancer

Abstract Background

Primary androgen deprivation therapy (pADT) is commonly used to treat elderly men diagnosed with localized prostate cancer (CaP), despite the lack of evidence supporting its use.

Objective

To examine the effect of pADT on mortality and to assess contemporary trends of pADT use in elderly men with CaP.

Design, setting, and participants

Men older than 65 yr residing in Surveillance, Epidemiology, and End Results (SEER) registry areas diagnosed with localized or locally advanced CaP between 1992 and 2009 and not receiving definitive therapy.

Outcome measurements and statistical analysis

Propensity score (PS)-weighted Cox proportional hazards models were used to estimate the effect of pADT use on overall survival among patients receiving pADT. The interaction between comorbidity-adjusted life expectancy (LE) and pADT use was assessed within the Cox and PS-weighted models. Contemporary (2004–2009) trends for pADT use were analyzed by linear regression.

Results and limitations

The primary cohort included 46 376 men, of whom 17 873 received pADT (39%). Patients with >10 yr LE had lower pADT utilization rates than patients with short LE. Between 2004 and 2009, the use of pADT in men with localized CaP decreased by 14% (from 36% to 22%). Relative to observation, pADT was associated with a survival disadvantage, with a hazard ratio for all-cause mortality of 1.37 (95% confidence interval 1.20–1.56). Limitations included biases not accounted for by the PS-weighted model, changes in CaP staging over the study period, the absence of prostate-specific antigen (PSA) data prior to 2004, and the limits of retrospective analysis to demonstrate causality.

Conclusions

The use of pADT in elderly men with localized CaP has decreased over time. For men forgoing primary definitive therapy, the use of pADT is not associated with a survival benefit compared to observation, and denies men an opportunity for cure with definitive therapy. The deleterious effect of pADT is most pronounced in men with prolonged LE.

Patient summary

In this report, we assessed the effect of primary androgen deprivation (pADT) on prostate cancer mortality and determined current trends in the use of pADT. We showed that use of pADT in men aged >65 yr with localized prostate cancer has decreased over time. We also found that pADT is detrimental to men with localized prostate cancer, and particularly men with longer life expectancy. Therefore, we conclude that ADT should not be used as a primary treatment for men with prostate cancer that has not spread beyond the prostate.

Take Home Message

Assessment of contemporary treatment patterns demonstrates a decrease in the use of primary androgen deprivation therapy (pADT) for men diagnosed with localized prostate cancer. The use of pADT confers no survival benefit compared to observation, especially for men with prolonged life expectancy, and denies men an opportunity for cure with definitive therapy.

Keywords: Prostate cancer, Medicare, Androgen deprivation, SEER.

Footnotes

a VUI Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA

b Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital / Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA

c Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

d Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

e Department of Urology, Yale University, New Haven, CT, USA

f Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada

g Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

Corresponding author. Center for Surgery and Public Health, 45 Francis St, ASB II-3, Boston, MA 02115, USA. Tel. +1 617 525 7350; Fax: +1 617 525-6348.

Article information

PII: S0302-2838(14)01026-4
DOI: 10.1016/j.eururo.2014.10.018
© 2014 European Association of Urology, Published by Elsevier B.V.

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Bone-related Parameters are the Main Prognostic Factors for Overall Survival in Men with Bone Metastases from Castration-resistant Prostate Cancer

Abstract Background

Previous studies have reported on prognostic factors for castration-resistant prostate cancer (CRPC); however, most of these studies were conducted before docetaxel chemotherapy was approved for CRPC.

Objective

To evaluate the prognostic value of multiple parameters in men with bone metastases due to CRPC using a contemporary dataset.

Design, setting, and participants

The analysis included 1901 patients with metastatic CRPC enrolled in an international, multicenter, randomized, double-blind phase 3 trial conducted between May 2006 and October 2009.

Outcome measures and statistical analysis

We developed multivariate validated Cox proportional hazards models and nomograms to estimate 12-mo and 24-mo survival probabilities and median survival time.

Results and limitations

The median (95% confidence interval) overall survival was 20 (18, 21) mo. The final model included 12 of the 15 potential prognostic variables evaluated (concordance index 0.72). Seven bone-related variables were associated with longer survival in the final model: alkaline phosphatase ≤143 U/l (p < 0.0001); bone-specific alkaline phosphatase (BSAP) <146 U/l (p < 0.0001); corrected urinary N-telopeptide (uNTx) ≤50 nmol/mmol (p = 0.0008); mild or no pain (Brief Pain Inventory—Short Form [BPI-SF] score ≤4) (p < 0.0001); no previous skeletal-related event (SRE;p = 0.0002); longer time from initial diagnosis to first bone metastasis (p < 0.0001); and longer time from first bone metastasis to randomization (p < 0.0001). Other significant predictors of improved survival included prostate-specific antigen (PSA) level <10 ng/ml (p < 0.0001), hemoglobin >128 g/l (p < 0.0001), absence of visceral metastases (p < 0.0001), Eastern Co-operative Oncology Group (ECOG) score ≤1 (p = 0.017), and younger age (p = 0.008). Nomograms were generated based on the parameters included in the final validated models (with/without uNTx and BSAP). One limitation was that lactate dehydrogenase (LDH) levels, a known prognostic factor, were not available in this study.

Conclusions

Bone-related parameters are strong prognostic variables for overall survival in patients with bone metastases from CRPC.

Patient summary

Survival time is variable in patients with bone metastases from prostate cancer. We found that factors related to bone help to predict how long a patient will live.

Take Home Message

Bone-related parameters were found to be strong predictors of overall survival in addition to established disease stage factors in multivariate analyses of a large clinical trial in patients with bone metastases due to castration-resistant prostate cancer.

Keywords: Castration-resistant prostate cancer, Bone metastases, Survival, Prognostic factors, Nomogram.

Footnotes

a Institut Gustave Roussy, University of Paris Sud, Villejuif, France

b Massachusetts General Hospital Cancer Center, Boston, MA, USA

c Nyack Hospital, Nyack, NY, USA

d Cancer Research UK Experimental Cancer Medicine Centres, Leeds and Sheffield, UK

e Department of Radiotherapy, Greater Poland Cancer Center and Department of Electroradiology, Medical University, Poznań, Poland

f Carolina Urologic Research Center, Myrtle Beach, SC, USA

g European Georges Pompidou Hospital, Paris, France

h The Urology Center of Colorado, Denver, CO, USA

i Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA

j Universitario Pedro Ernesto, Rio De Janeiro, Brazil

k Amgen Inc., Thousand Oaks, CA, USA

Corresponding author. Department of Cancer Medicine, Institut Gustave Roussy, University of Paris Sud, 39 rue Camille Desmoulins, 94800 Villejuif, France. Tel. +33 1 42114317; Fax: +33 1 42115217.

Article information

PII: S0302-2838(14)01009-4
DOI: 10.1016/j.eururo.2014.10.001
© 2014 European Association of Urology, Published by Elsevier B.V.

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Natural History after Biochemical Failure Following Dose-escalated External Beam Radiation: An Opportunity to Improve Outcomes?

Refers to article:

The Natural History and Predictors of Outcome Following Biochemical Relapse in the Dose Escalation Era for Prostate Cancer Patients Undergoing Definitive External Beam Radiotherapy

Zachary S. Zumsteg, Daniel E. Spratt, Paul B. Romesser, Xin Pei, Zhigang Zhang, William Polkinghorn, Sean McBride, Marisa Kollmeier, Yoshiya Yamada and Michael J. Zelefsky

Accepted 18 September 2014

Footnotes

University of California San Francisco (UCSF), San Francisco, CA, USA

University of California San Francisco (UCSF), Helen Diller Family Comprehensive Cancer Center, 1600 Divisadero Street, Suite H 1031, San Francisco, CA 94143-1708, USA. Tel. +1 415 3537181; Fax: +1 415 3539883.

Article information

PII: S0302-2838(14)01023-9
DOI: 10.1016/j.eururo.2014.10.015
© 2014 Published by Elsevier B.V.

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Fewer women than men receive hemodialysis treatment

MedicalNewsToday - Tue, 2014-10-28 13:00
Fewer women than men are treated with dialysis for end-stage kidney disease, according to a new comprehensive analysis of sex-specific differences in treatment published in PLOS Medicine.
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People who develop kidney stones may face increased bone fracture risk

MedicalNewsToday - Tue, 2014-10-28 02:00
People who develop kidney stones may be at increased risk of experiencing bone fractures, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of...
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Supine Transgluteal vs Prone Position in Extracorporeal Shock Wave Lithotripsy of Distal Ureteric Stones

Urology (Gold Journal) In Press - Tue, 2014-10-28 00:00
To evaluate of efficacy of transgluteal (supine) approach for shock wave lithotripsy (SWL) in treatment of distal ureteric stones.
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Editorial Comment

This retrospective series represents a clear paradigm shift toward identification of the ideal case of VUR that can be managed by active surveillance. The study mirrors other historical retrospective series. However, this study represents the youngest population to be managed in this manner (references 2 and 6 in article). The authors attempt to address the fundamental aspect of this disease that we should focus on moving forward, ie who becomes infected as opposed to who has resolution of VUR. The former is much more important than the latter.
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A Multi-institutional Prospective Trial in the USA Confirms that the 4Kscore Accurately Identifies Men with High-grade Prostate Cancer

Abstract Background

The 4Kscore combines measurement of four kallikreins in blood with clinical information as a measure of the probability of significant (Gleason ≥7) prostate cancer (PCa) before prostate biopsy.

Objective

To perform the first prospective evaluation of the 4Kscore in predicting Gleason ≥7 PCa in the USA.

Design, setting, and participants

Prospective enrollment of 1012 men scheduled for prostate biopsy, regardless of prostate-specific antigen level or clinical findings, was conducted at 26 US urology centers between October 2013 and April 2014.

Intervention

The 4Kscore.

Outcome measurements and statistical analysis

The primary outcome was Gleason ≥7 PCa on prostate biopsy. The area under the receiver operating characteristic curve, risk calibration, and decision curve analysis (DCA) were determined, along with comparisons of probability cutoffs for reducing the number of biopsies and their impact on delaying diagnosis.

Results and limitations

Gleason ≥7 PCa was found in 231 (23%) of the 1012 patients. The 4Kscore showed excellent calibration and demonstrated higher discrimination (AUC 0.82) and net benefit compared to a modified Prostate Cancer Prevention Trial Risk Calculator 2.0 model and standard of care (biopsy for all men) according to DCA. A possible reduction of 30–58% in the number biopsies was identified with delayed diagnosis in only 1.3–4.7% of Gleason ≥7 PCa cases, depending on the threshold used for biopsy. Pathological assessment was performed according to the standard of care at each site without centralized review.

Conclusion

The 4Kscore showed excellent diagnostic performance in detecting significant PCa. It is a useful tool in selecting men who have significant disease and are most likely to benefit from a prostate biopsy from men with no cancer or indolent cancer.

Patient summary

The 4Kscore provides each patient with an accurate and personalized measure of the risk of Gleason ≥7 cancer to aid in decision-making regarding the need for prostate biopsy.

Take Home Message

The 4Kscore accurately predicts the probability of significant cancer on prostate biopsy. The test showed excellent calibration and discrimination for Gleason ≥7 cancer and is helpful for shared decision-making regarding the need for prostate biopsy.

Keywords: Biomarkers, Prostate cancer, Screening, Biopsy.

Footnotes

a Department of Urology, University of Miami Miller School of Medicine and Sylvestor Comprehensive Cancer Center, Miami, FL, USA

b Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

c Delaware Valley Urology, Mt Laurel, NJ, USA

d First Urology, Jeffersonville, IN, USA

e Urology Clinics of North Texas, Dallas, TX, USA

f Urology Associates, Nashville, TN, USA

g Skyline Urology, Sherman Oaks, CA, USA

h Alliance Research Centers, Laguna Hills, CA, USA

i The Urology Group, Cincinnati, OH, USA

j Central Ohio Urology Group, Columbus, OH, USA

k Atlantic Urological Associates, Daytona, FL, USA

l Regional Urology, Shreveport, LA, USA

m The Urology Center of Colorado, Denver, CO, USA

n Delaware Valley Urology, Voorhees, NJ, USA

o Arkansas Urology, Little Rock, AR, USA

p University of Washington, Seattle, WA, USA

q Adult and Pediatric Urology, Sarteli, MN, USA

r Manchester Urology, Manchester, NH, USA

s Associated Medical Professionals of NY, Syracuse, NY, USA

t Lahey Hospital and Medical Center, Burlington, MA, USA

u Urology San Antonio, San Antonio, TX, USA

v Urology of Indiana, Greenwood, IN, USA

w Atlantic Urology Clinics, Myrtle Beach, SC, USA

x Lancaster Urology, Lancaster, PA, USA

y Idaho Urologic Institute, Meridian, ID, USA

z Skyline Urology, Torrance, CA, USA

aa Andover Urology, Andover, MA, USA

Corresponding author. University of Miami, 1120 NW 14th Street, Suite 1560, Miami, FL 33136, USA. Tel. +1 305 2436591; Fax: +1 305 2436597.

Article information

PII: S0302-2838(14)01035-5
DOI: 10.1016/j.eururo.2014.10.021
© 2014 European Association of Urology, Published by Elsevier B.V.

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Preliminary Results of a Randomised Controlled Trial of an Online Psychological Intervention to Reduce Distress in Men Treated for Localised Prostate Cancer

Abstract Background

Prostate cancer (PCa) poses many emotional and physical challenges for men following treatment. The unmet support needs of these men are well documented, and access to psychosocial support remains problematic.

Objectives

To assess the efficacy of an online psychological intervention for men who have localised PCa.

Design, setting, and participants

We undertook a randomised controlled trial to evaluate the intervention. Participants were randomly allocated to one of three conditions: My Road Ahead (MRA) alone (MRA Only), MRA plus access to an online forum (MRA + Forum), and access to the forum alone (Forum).

Intervention

The intervention was a 10-week self-guided online psychological intervention calledMy Road Aheadthat consisted of six themed modules designed to facilitate improved emotional well-being in the context of PCa as well as a moderated peer forum.

Outcome measurements and statistical analysis

Pre- and postintervention assessments of psychological distress (the 21-question Depression, Anxiety and Stress Scale) [1] and the Prostate Cancer–related Quality of Life scale [2] were conducted. Multivariate analysis of variance, regression, and structural equation modelling were used to analyse the data.

Results and limitations

In total, 142 participants were randomly allocated to one of the three intervention arms. The mean age of participants was 61 yr of age (standard deviation: 7), and 88% had undergone radical prostatectomy. A significant improvement in psychological distress was observed for participants who had access to the combined condition (MRA + Forum) with a moderate effect size (p = 0.02; partialη2 = 0.07). In particular, the decline in the mean level of psychological distress was 8.8 units larger for the MRA + Forum group than the Forum group (95% confidence interval [CI], 0.9–16.7). Although the decline in the mean level of psychological distress was 7.0 units larger for the MRA + Forum group than for the MRA Only group, this difference was not significant (95% CI, 1.1–15.1). Structural equation modelling indicated that reductions in health worry and regret contributed significantly to the reductions in psychological distress for the MRA + Forum condition.

Conclusions

This study is the first, to our knowledge, that has evaluated a self-guided online psychological intervention tailored to the specific needs of men who have PCa. The findings of this study indicate the potential for this programme to deliver support that men may not otherwise receive.

Patient summary

This study found that men who have localised prostate cancer who received access to the online psychological intervention calledMy Road Aheadcombined with the online peer discussion forum had significantly improved reductions in distress compared with those who received access to the online intervention alone or the forum alone.

Take Home Message

The delivery of an online psychological intervention combined with a peer support forum is effective in reducing psychological distress for men following treatment for localised prostate cancer.

Keywords: Prostate cancer, Distress, Psychological intervention, Survivorship, Quality of life.

Footnotes

a Department of Urology, Royal Melbourne Hospital, Parkville, Victoria, Australia

b Epworth Prostate Centre, Epworth Healthcare, Richmond, Victoria, Australia

c Australian Prostate Cancer Research, East Melbourne, Victoria, Australia

d National eTherapy Centre, Swinburne University of Technology, Hawthorn, Victoria, Australia

e Department of Psychology, Deakin University, Burwood, Victoria, Australia

f DVC-Research & Innovation Portfolio, the School of Health Sciences, and the Collaborative Research Network, Federation University, Ballarat, Australia

g National Institute for Mental Health Research, The Australian National University, Canberra, Australia

h Faculty of Health, Arts and Design, Swinburne University of Technology, Hawthorn, Victoria, Australia

i Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia

Corresponding author. Department of Urology, Royal Melbourne Hospital, Parkville, Victoria, Australia. Tel. +61 402 903 101; Fax: +61 3 9429 4683.

Article information

PII: S0302-2838(14)01038-0
DOI: 10.1016/j.eururo.2014.10.024
© 2014 European Association of Urology, Published by Elsevier B.V.

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Degree of Preservation of the Neurovascular Bundles During Radical Prostatectomy and Urinary Continence 1 Year after Surgery

Abstract Background

Many elderly or impotent men with prostate cancer may not receive a bundle-preserving radical prostatectomy as a result of uncertainty regarding the effect on urinary incontinence.

Objective

We searched for predictors of urinary incontinence 1 yr after surgery among surgical steps during radical prostatectomy.

Design, setting, and participants

More than 100 surgeons in 14 centers prospectively collected data on surgical steps during an open or robot-assisted laparoscopic radical prostatectomy. At 1 yr after surgery, a neutral third-party secretariat collected patient-reported information on urinary incontinence. After excluding men with preoperative urinary incontinence or postoperative irradiation, data were available for 3379 men.

Intervention

Surgical steps during radical prostatectomy, including dissection plane as a measure of the degree of preservation of the two neurovascular bundles.

Outcome measurements and statistical analysis

Urinary incontinence 1 yr after surgery was measured as patient-reported use of pads. In different categories of surgical steps, we calculated the percentage of men changing pads “about once per 24 h” or more often. Relative risks were calculated as percentage ratios between categories.

Results and limitations

A strong association was found between the degree of bundle preservation and urinary incontinence 1 yr after surgery. We set the highest degree of bundle preservation (bilateral intrafascial dissection) as the reference category (relative risk = 1.0). For the men in the remaining six groups, ordered according to the degree of preservation, we obtained the following relative risks (95% confidence interval [CI]): 1.07 (0.63–1.83), 1.19 (0.77–1.85), 1.56 (0.99–2.45), 1.78 (1.13–2.81), 2.27 (1.45–3.53), and 2.37 (1.52–3.69). In the latter group, no preservation of any of the bundles was performed. The pattern was similar for preoperatively impotent men and for elderly men. Limitations of this analysis include the fact that noise influences the relative risks, due to variations between surgeons in the use of undocumented surgical steps of the procedure, variations in surgical experience and in how the surgical steps are reported, as well as variations in the metrics of patient-reported use of pads.

Conclusions

We found that the degree of preservation of the two neurovascular bundles during radical prostatectomy predicts the rate of urinary incontinence 1 yr after the operation. According to our findings, preservation of both neurovascular bundles to avoid urinary incontinence is also meaningful for elderly and impotent men.

Patient summary

We studied the degree of preservation of the two neurovascular bundles during radical prostatectomy and found that the risk of incontinence decreases if the surgeon preserves two bundles instead of one, and if the surgeon preserves some part of a bundle rather than not doing so.

Take Home Message

Sexual inactivity or old age should not be considered a factor in decisions concerning the extent to which the neurovascular bundles are preserved during radical prostatectomy, because the degree of preservation predicts the rate of urinary incontinence in all survivors.

Keywords: Prostate cancer, Radical prostatectomy, Surgical technique, Urinary continence, Anatomy, Neurovascular bundle, Nerve-sparing surgery.

Footnotes

a Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

b Department of Oncology and Pathology, Division of Clinical Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden

c Department of Urology, Skåne University Hospital, Lund University, Lund, Sweden

d Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

e Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden

f Faculty of Nursing, University of Iceland, Reykjavik, Iceland

g Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

h UroClinic, Stockholm, Sweden

i Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden

Corresponding author. Clinical Cancer Epidemiology, Sahlgrenska Academy, University of Gothenburg, Box 100, 405 30 Gothenburg, Sweden.

1 Eva Haglind is the PI and Gunnar Steineck the co-PI of LAPPRO.

Article information

PII: S0302-2838(14)01019-7
DOI: 10.1016/j.eururo.2014.10.011
© 2014 Published by Elsevier B.V.

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Response to Crizotinib in a Patient with MET-mutant Papillary Renal Cell Cancer After Progression on Tivantinib

Footnotes

a Rutgers Cancer Institute of New Jersey; Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA

b Rutgers Cancer Institute of New Jersey; Department of Pathology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA

c Rutgers Cancer Institute of New Jersey; Section of Urologic Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA

d Foundation Medicine, Cambridge, Massachusetts, USA

Corresponding author. Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08903, USA.

Article information

PII: S0302-2838(14)01020-3
DOI: 10.1016/j.eururo.2014.10.012
© 2014 European Association of Urology, Published by Elsevier B.V.

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