Routine scrotal ultrasonography during the follow‐up of patients with testicular cancer leads to earlier detection of asynchronous tumours and a high rate of organ preservation

Study Type – Diagnosis (case series)
Level of Evidence 4

OBJECTIVE

To compare outcomes of patients with asynchronous tumours detected before and after the introduction of scrotal ultrasonography (SUS) during routine follow‐up examinations.

PATIENTS AND METHODS

Since January 2001 SUS was also used during the follow‐up of patients with testicular cancer. A series of 16 consecutive patients with asynchronous bilateral testicular tumours diagnosed while still complying with routine follow up investigations were identified and divided into two groups; group A was diagnosed by palpation only, before 2001, and group B was diagnosed after 2000. The groups were compared statistically for the interval between asynchronous tumours, clinical stage, tumour diameter at the time of diagnosis and rate of testis‐sparing surgery.

RESULTS

All tumours in group A were diagnosed by palpation, but only two in group B were palpable at the time of diagnosis. The mean tumour diameter was statistically significantly smaller in group B (1.2 cm) than in group A (2.68 cm); testis‐sparing surgery was used in all of group B and only three patients in group A. After organ‐sparing surgery all patients had normal testosterone levels. All patients after organ‐sparing surgery had adjuvant scrotal radiotherapy because of germ cell tumour, and no patient had a local recurrence.

CONCLUSION

Our data indicate that using SUS for the remaining testicle in routine follow‐up visits of patients with testicular cancer leads to the earlier detection of smaller tumours and, consequently, a higher rate of organ preservation. The maintenance of physiological endocrine function might finally result in a better quality of life.     

Increased incidence of Leydig cell tumours of the testis in the era of improved imaging techniques

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Leydig cell tumours (LCTs) of the testis are rare tumours, accounting for 1–3% of all testicular neoplasms. Our data indicate that using scrotal ultrasound with high resolution imaging in routine checkups leads to an earlier detection of LCTs. Most patients underwent an organ‐sparing surgery and no androgen deprivation was observed.

OBJECTIVE

? To report an observed high frequency of Leydig cell tumours (LCTs) diagnosed at our centre.

PATIENTS AND METHODS

? Charts of all patients who underwent surgery for a testicular tumour between 1999 and 2008 at our department were searched and data from patients with LCT were collected. ? Before surgery all patients underwent ultrasound and complete staging. In all but two patients with LCT an organ‐sparing surgery was performed. Surgery was performed under ultrasound or palpation guidance. ? All patients underwent postoperative follow‐up. We retrospectively reviewed surgical technique, histology, epidemiology and outcome in all LCT patients.

RESULTS

? In the study period, 197 testicular tumours were surgically removed of which 29 were diagnosed as LCT (14.7% of 197; further study group) in 25 patients. Mean age of patients with LCT was 45 years (range 21–68 years). ? Tumour size ranged from 1.2 to 80 mm (mean 10.23 mm). In two patients (8%) the lesion was palpable whereas incidental diagnosis was made in seven patients (28%). ? In the remaining patients diagnosis was made by ultrasound performed for testicular pain (six patients, 24%) or during infertility or erectile dysfunction evaluation (10 patients, 40%). ? Definitive histology reported no malignant histopathological features in all but one patient; this particular patient experienced tumour progression after 2 months and died from advanced disease 1 year later. All other patients are free of disease after a mean follow up of 56 months (range 7–93 months). ? During this period one patient developed a second LCT on the contralateral side; another patient had a recurrence within the same testicle, but on the opposite pole. Both underwent a subsequent organ‐sparing tumour resection.

CONCLUSION

? The percentage of LCT (14.7% of all testicular tumours removed) was significantly higher than expected from the literature. One possible explanation for this phenomenon is the increasing use of better ultrasound technology and the subsequent increased detection of small nodules that have not been found in historical series. Use of ‘observation‐only’ for very small lesions detected at infertility clinics is under debate.     

Testicular lesions other than germ cell tumours: feasibility of testis-sparing surgery

OBJECTIVE

To review all non‐germ‐cell testicular lesions presenting at our institution and to determine the feasibility of testis‐sparing surgery for these patients.

PATIENTS AND METHODS

All surgery for testicular masses between June 1995 and June 2005 were reviewed retrospectively. Patients with atrophy, germ cell tumours, infection or torsion were excluded. The study comprised men who had radical orchidectomy for suspected germ‐cell tumour but had other final pathology, and those where testis‐sparing surgery was attempted for a presumed benign lesion.

RESULTS

Thirteen patients with lesions appropriate for the study were identified; all but one had a palpable lesion. The lesions could be categorized as inflammatory (three hyalinized fibrosis, two sarcoidosis, one chronic inflammation), cystic (one epidermoid cyst, one unilocular cyst), benign neoplasms (two adenomatoid tumours, one Leydig cell tumour, one capillary haemangioma) or malignant neoplasms (one lymphoma). Based on the preoperative impression, testis‐sparing surgery was attempted in eight of the lesions and was successful in six where it was attempted. In the other five, testis‐sparing surgery was not attempted because the preoperative impression was that of a germ cell tumour. Testis‐sparing surgery was successful in only six of the 13 patients with these lesions.

CONCLUSION

Testis‐sparing surgery might be possible if there is significant suspicion of a benign lesion. If frozen‐section analysis is equivocal, a radical orchidectomy is required. Testis‐sparing surgery was feasible in highly selected cases.     

Prepubertal testicular tumours and efficacy of testicular preserving surgery

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Testicular tumours in childhood are very rare. Historically, most of these tumours have been considered malignant, but more recent studies indicate that benign lesions, particularly teratoma, are much more frequent than previously thought. Testicular tumours in this age group have traditionally been treated with inguinal radical orchiectomy, but more conservative management has been proposed in view of the higher frequency of benign tumours. In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers.

OBJECTIVE

? To report our experience of testicular tumours in children aged ≤13 years, including our experience with testis‐sparing surgery.

PATIENTS AND METHODS

? A retrospective study was performed of 15 patients with testicular tumours aged ≤13 years who presented at our centre between 1984 and 2008. The use of testis‐preserving surgery according to indication was investigated and outcomes were recorded.

RESULTS

? The clinical presentation was increased testicular size with a palpable mass in 80% of the cases. All 15 patients underwent surgery. The tumour was benign in 12 (80%) patients and malignant in three (20%) patients. ? Organ‐preserving surgery was planned and achieved in 11 patients (73%). ? Pathology of the tumourectomy specimens disclosed benign tumours in all cases: four epidermoid cysts, two teratomas, one juvenile granulosa cell tumour, one haemangioma, one lipoma, one fibrous hamartoma and one splenogonadal fusion. ? In four patients who underwent radical orchiectomy, pathology identified one yolk sac tumour (stage I), two mixed germ cell tumours and one gonadoblastoma.

CONCLUSIONS

? In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers. ? The lesion, however, should be thoroughly excised to avoid recurrences.     

Varicocele surgery: a decade’s experience at a children’s hospital

OBJECTIVES

To review our experience at a children’s hospital over a 10‐year period with the Palomo, Ivanissevich, subinguinal and laparoscopic techniques for varicocele, assessing the success and complication rates according to specific procedure, and the added effect that the modifications of microsurgery and artery‐sparing has had on these rates. A second objective was to assess the rate of testicular compensatory growth after surgery for testicular hypotrophy.

PATIENTS AND METHODS

Ninety‐two patients with >1 year of follow‐up between 1996 and 2006 were assessed retrospectively. The median (range) age at surgery was 15 (8–21) years. Patients were stratified based on the surgical technique used by eight different urology faculty members. Microsurgery and attempted artery‐sparing were applied to some Palomo, Ivannisevich, and subinguinal cases but not to laparoscopic procedures.

RESULTS

The laparoscopic (100%) and Palomo (93%) techniques had significantly higher success rates than the Ivanissevich approach (69%). The success rate with the subinguinal technique (88%) was intermediate between the more successful supra‐inguinal and less successful inguinal approaches. There was a higher hydrocele rate (32%) in the laparoscopic approach. Artery sparing significantly lowered hydrocele rates but had no effect on success rates. Incorporating microsurgery also had no effect on success rates but resulted in no hydrocele formation. One case of testicular atrophy occurred in a patient undergoing microsurgical artery‐sparing subinguinal spermatic vein ligation. There was compensatory growth in 68% of patients operated on for testicular hypotrophy.

CONCLUSIONS

During our 10‐year experience the laparoscopic and Palomo approaches were the most successful. The subinguinal approach (usually incorporating microsurgery and artery sparing) had an intermediate success rate. The Ivanissevich approach was least successful. Hydroceles did not occur when microsurgery was used, and were significantly less common with artery sparing. The only case of testicular atrophy was with a microsurgical artery‐sparing subinguinal approach. When the spermatic vein was ligated for testicular hypotrophy there was compensatory growth in two‐thirds of testes.     

Extracorporeal high intensity focused ultrasound for renal tumours: a 3‐year follow‐up

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine whether primary extracorporeal high‐intensity focused ultrasound (HIFU) is safe, feasible and effective for managing small renal tumours.

PATIENTS AND METHODS

Although surgery currently remains the standard treatment for localized renal cell carcinoma (RCC), the increasing incidence of small renal cancers has led to a shift towards nephron‐sparing surgery, with associated morbidity in 20–25% of cases, and minimally invasive ablative therapies present an alternative management. HIFU results in ‘trackless’ homogenous tissue ablation and when administered via an extracorporeal device, is entirely noninvasive. The study comprised 17 patients (mean tumour size 2.5 cm) with radiologically suspicious renal tumours who underwent extracorporeal HIFU using the Model‐JC System (Chongqing HAIFU^TM, China), under general anaesthesia with one overnight hospital stay. Real‐time diagnostic ultrasonography was used for targeting and monitoring. Patients were followed with a clinical review and gadolinium‐enhanced magnetic resonance imaging at 12 days and every 6 months for a mean of 36 months. The outcomes measures were patient morbidity and oncological efficacy of HIFU treatment.

RESULTS

Of the 17 patients, 15 were treated according to protocol; two procedures were abandoned due to intervening bowel. There were no major complications related to HIFU. Radiological evidence of ablation was apparent at 12 days in seven of the 15 patients. Before the 6‐month follow‐up one patient had surgery due to persisting central enhancement. Fourteen patients were evaluated at the 6‐month follow‐up; eight tumours had involuted (mean 12% decrease in tumour area). Four patients had irregular enhancement on imaging and had alternative therapies. Ten patients remain on follow‐up at a mean (range) of 36 (14–55) months after HIFU (mean 30% decrease in tumour area). There was central loss of enhancement in all.

CONCLUSIONS

Renal HIFU achieves stable lesions in two‐thirds of patients, with minimal morbidity, and might be appropriate in selected cases. Further trials with accurate histological follow‐up are essential to fully evaluate this novel technique.     

Organ-sparing surgery is the treatment of choice in benign testicular tumors

Purpose

Ablation of the testis has been the reference standard for malignant and benign testicular tumors in the past. Nowadays, an organ-sparing surgery (OSS) can be attempted in special cases. Removal of a testis for a benign lesion should be avoided. In this retrospective survey, we analyze the results and long-term follow-up of OSS in benign testicular tumors.

Methods

Charts of all patients that underwent OSS because of a benign testicular tumor between 1999 and 2011 at our department were searched and the data from patients were collected. Before surgery, all patients underwent ultrasound (US) and complete staging. Surgery was performed under US or palpation guidance. Frozen-section examination of the tumor and tumor bed biopsies was obtained. All patients underwent postoperative follow-up. We retrospectively reviewed surgical technique, histology, epidemiology, and outcome in all patients.

Results

In the study period, 40 benign testicular tumors were surgically removed in 37 consecutive patients. Definitive histology did not report of any malignant histopathologic features in all patients. All patients are free of disease after a mean follow-up of 63 months (range 10–120). During this period, two patients developed a second leydig cell tumor (LCT) on the contralateral side; another patient had a second LCT within the same testicle, but on the opposite pole. All patients underwent a subsequent organ-sparing tumor resection.

Conclusions

An overtreatment for benign testicular tumors should be avoided. Our initial results indicate that OSS in benign tumors is a safe, feasible treatment for patients.     

High prevalence of hypogonadism determined by serum free testosterone level in Japanese testicular cancer survivors

Objective

Hypogonadism is a major complication in testicular cancer survivors, but its prevalence varies among studies. In Japan, free testosterone has been used for diagnosis of late‐onset hypogonadism syndrome. In the present study, we evaluated the hormone level of testicular cancer survivors and its impact on their quality of life.

Methods

Overall, 50 testicular cancer survivors treated from 1990 to 2013 were enrolled. The median age was 44 years. The serum levels of free testosterone, total testosterone and luteinizing hormone were measured. All patients completed the Aging Males’ Symptom scale and International Index of Erectile Function‐15. The hormone levels of 337 healthy volunteers were used as the control.

Results

A total of 32 (64%) patients showed free testosterone levels <8.5 pg/mL. In contrast, just 26% of 50 patients showed total testosterone levels <3.5 ng/mL. Testicular cancer survivors had significantly lower free testosterone and higher luteinizing hormone compared with healthy controls. In contrast, there was no difference in total testosterone between patients and controls. The prevalence of late‐onset hypogonadism symptoms of any grade (Aging Males’ Symptom total score ≥27) was 60%. Overall, 64% were defined as having moderate erectile dysfunction (International Index of Erectile Function‐Erectile Function domain score <17). However, Aging Males’ Symptom, International Index of Erectile Function‐15 and Erectile Function domain scores did not differ by free testosterone or total testosterone level.

Conclusions

This is the first report on the prevalence of hypogonadism determined by free testosterone level in Japanese testicular cancer survivors. Because Aging Males’ Symptom and International Index of Erectile Function‐15 scores do not necessarily reflect the hormone level, measuring free testosterone is also important in the follow up of these patients.     

Carcinoid tumours of the testis

OBJECTIVE

To review previous reports of carcinoid (an endocrine tumour mostly of the gastrointestinal tract) tumours of the testis.

METHODS

Carcinoid tumours of the testis are rare and can be divided into primary carcinoid (group 1), testicular metastasis from another location (group 2) and carcinoid within a testicular teratoma (group 3). A case of testicular carcinoid within our clinic prompted us to review previous reports; all the cases found were assessed for patient and tumour characteristics, diagnostic tools used, treatment and prognosis.

RESULTS

In all, 62 cases were assessed and divided into groups 1 (44 patients), 2 (six) and 3 (12), respectively. Seven patients in group 1 developed metastases. A wide variety of diagnostic tools was used to search for other tumour sites. All patients were treated with orchidectomy. Three patients with a primary carcinoid were treated with adjuvant chemotherapy (two) or radiotherapy (one), with unknown results. All but one of the nine patients who died were known to have metastasis, either from a primary testicular carcinoid or testicular metastases from an intestinal carcinoid.

CONCLUSION

When a testicular carcinoid tumour is discovered, other tumour sites should be excluded. The most useful diagnostic tools for this purpose seem to be urinary 5‐hydroxyindoleacetic acid measurement, somatostatin receptor scintigraphy, computed tomography and video‐capsule endoscopy. Localized testicular carcinoid tumours have an excellent prognosis after orchidectomy.     

Tumour in solitary kidney: laparoscopic partial nephrectomy vs laparoscopic cryoablation

Study Type – Therapy (cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Tumour in a solitary functioning kidney represents an absolute indication for nephron‐sparing surgery whenever technically feasible. We report the longest follow‐up data comparing laparoscopic partial nephrectomy and laparoscopic cryoablation in patients with solitary kidney with oncological follow‐up to five years.

OBJECTIVES

? We compare perioperative, functional and intermediate‐term oncological outcomes of laparoscopic partial nephrectomy (LPN) vs laparoscopic cryoablation (LCA) for small renal tumour in patients with a solitary kidney. ? A treatment algorithm is also proposed.

PATIENT AND METHODS

? Over a 10‐year period (02/1998‐09/2008), 78 patients with a small tumour in a functionally solitary kidney underwent LPN (n= 48) or LCA (n= 30). ? Baseline, perioperative, and follow‐up data were collected prospectively and analyzed retrospectively.

RESULTS

? Demographic data were similar between the LPN and LCA groups. Tumours were somewhat larger (3.2 vs 2.6 cm) in the LPN group. LPN was associated with greater blood loss (391 vs 162 mL; P= 0.003), and trended towards more post‐operative complications (22.9% vs 6.7%; P= 0.07). ? By 3 months post‐operative, eGFR decreased by 14.5% and 7.3% after LPN and LCA, respectively (P= 0.02). Post‐operative temporary dialysis was required after 3 LPN (6.2% vs 0%, P= 0.16). ? Median follow‐up time for LPN and LCA was 42.7 and 60.2 months, respectively. ? Local recurrence was detected in 4 (13.3%) LCA patients only (P= 0.02). ? Overall survival was comparable between LPN and LCA at 3 and 5 years, respectively (P= 0.74). The LPN group had superior cancer‐specific and recurrence‐free survival at 3 and 5 years compared to the LCA group (P < 0.05, for all comparisons).

CONCLUSIONS

? Given adequate technical expertise, both LPN and LCA are viable nephron‐sparing options for patients with tumour in a solitary kidney. ? Although LCA is technically easier and has superior functional outcomes, oncologic outcomes are superior after LPN.     

Long-term outcome of multiple ipsilateral renal tumours found at the time of planned nephron-sparing surgery

OBJECTIVE

To evaluate patients with multiple ipsilateral renal tumours and to determine outcomes of nephron‐sparing surgery (NSS) and radical nephrectomy (RN), as the treatment of unrecognized sporadic multifocal tumours at NSS presents a surgical dilemma.

PATIENTS AND METHODS

In all, 104 patients had surgery between 1970 and 2003 for sporadic multiple ipsilateral renal tumours, at least one of which was renal cell carcinoma (RCC); 114 were treated with RN and 26 with NSS. Cancer‐specific survival (CSS) was estimated using the Kaplan‐Meier method.

RESULTS

More patients treated with NSS had a solitary kidney than those undergoing RN (six, 23%, vs none, P < 0.001). Seventeen of the 114 having RN died from RCC at a median (range) of 3.4 (0.25–10.3) years after RN. The estimated 5‐year CSS was 90.5%. There was metachronous recurrence in nine patients at a median of 5.6 (1–14 ) years after. Two of the 26 patients having NSS died from RCC at 1 and 6 years after NSS; the 5‐year CSS was 95.8%. There was local or metachronous recurrence in three patients at 7 months to 6 years after surgery; all three were alive at the last follow‐up. In 26 (23%) of the 114 patients treated with RN, only one tumour was RCC.

CONCLUSION

Patients undergoing either RN or NSS for multiple ipsilateral renal tumours have a favourable CSS. A planned NSS is safe if small satellite lesions are resectable.     

The impact of family history on pathological and clinical outcomes in non‐syndromic clear cell renal cell carcinoma

Study Type – Prognosis (case series)
Level of Evidence 4

OBJECTIVE

To investigate the impact of family history on pathological and clinical outcomes after surgery for clear‐cell renal cell carcinoma (ccRCC) in patients with non‐syndromic disease.

PATIENTS AND METHODS

We reviewed 2677 patients treated with radical nephrectomy or nephron‐sparing surgery for non‐cystic ccRCC between 1970 and 2004 to identify patients with a family history of ccRCC. Patients with von Hippel–Lindau, tuberous sclerosis, or Birt–Hogg–Dube syndrome were excluded from analysis. Demographics and clinico‐pathological outcomes were compared to patients with ccRCC without a family history of kidney cancer using chi‐squared and Fisher’s exact tests. Postoperative cancer‐specific survival was estimated using the Kaplan–Meier method.

RESULTS

We identified 42 patients (1.6%) with a family history of ccRCC who were treated for non‐cystic ccRCC, with a median follow‐up of 4.7 years (range 1–34). Demographics and tumour characteristics, including tumour stage and grade, were similar between the two groups. Patients with a family history of ccRCC were more likely to have bilateral tumours (11.9 vs 2.2%, P= 0.003). Nevertheless, cancer‐specific survival rates for patients with and without a family history of ccRCC were similar at 5 years (75.7 vs 71.1%) and 10 years (53.9 vs 62.2%).

CONCLUSIONS

Patients with a family history of ccRCC have pathological and clinical outcomes similar to patients with sporadic ccRCC. The increased incidence of bilateral tumours associated with a family history of ccRCC provides further evidence to support a nephron‐sparing surgical approach when feasible.     

Twenty‐nine Leydig cell tumors: Histological features,outcomes and implications for management

Leydig cell tumors are the most common interstitial neoplasm of the testes. Metastatic progression is historically quoted at over 10%, fuelling uncertainty as to the safety of testis sparing surgery. Between June 1998 and March 2009, 29 patients underwent surgery for Leydig cell tumor of the testis in our cancer network. We reviewed their histological features and clinical outcomes. Four patients with sub‐5 millimetre lesions underwent testis sparing surgery and 25 were treated with radical orchidectomy. Histopathological characteristics that have been linked with risk of malignant progression were seen infrequently in our cohort: diameter greater than 50 mm, 0%; nuclear atypia, 14%; >3 mitoses per 10 high‐power fields, 3%; infiltrative borders, 10%; necrosis, 3%; and vascular invasion 0%. No patient developed local or distant recurrent disease over a median follow up of 49 months, including seven and four patients disease‐free at 5 and 10 years, respectively. The rate of metastatic progression is likely to be significantly less than 10%. Our data suggest that, in the absence of high‐risk histopathological features, this tumor can be safely regarded as benign, pending a longer‐term follow‐up evaluation.     

Outcome of nephron‐sparing surgery for T1b renal cell carcinoma

OBJECTIVE

To present our experience with nephron‐sparing surgery (NSS) for T1b renal cell carcinoma (RCC) in a high‐volume tertiary referral centre. NSS for RCC of <4 cm (T1a) is increasingly accepted, although its role for RCC of 4–7 cm (T1b) remains controversial.

PATIENTS AND METHODS

The records of 67 consecutive patients who had NSS for RCC of 4–7 cm at our institution were reviewed retrospectively. Data were collected on surgical indications, tumour characteristics, complications, changes in serum creatinine level, time to recurrence and time to death. Clinical progression‐free survival (CPFS), overall survival (OS), cancer‐specific survival (CSS) rates were estimated statistically.

RESULTS

The mean patient age was 62 years. Surgical indications were absolute in 26 (39%) patients, relative in 11 (16%) and elective in 30 (45%). Two patients (3%) required postoperative embolization, and none developed a urinary fistula. Four patients (6%) had positive resection margins; none of these developed tumour recurrence. After a median (range) follow‐up of 40.1 (1–98.3) months, 10 patients (15%) had died, of whom only one death was related to NSS (postoperative hypovolaemic shock). The tumour recurred in seven patients (10%) all of whom were alive at the last follow‐up. Three patients (4%) developed a local recurrence and four (6%) developed locoregional or distant disease. The projected 5‐year CPFS, CSS and OS rates were 84%, 99% and 72%, respectively. Seven (10%) patients developed de novo renal insufficiency. Elective and relative indications were not associated with a significant change in serum creatinine level (P = 0.22 and 0.10, respectively); in the absolute category this difference was statistically significant (P = 0.005). The main limitation is that the study was uncontrolled and retrospective, with a medium‐term follow‐up.

CONCLUSIONS

This study showed the excellent surgical feasibility and CSS for NSS in T1b RCC. Local cancer control was achieved in the large majority of patients, with preservation of renal function in those with elective indications. Absolute indications significantly correlated with loss of renal function.     

Factors affecting erectile function after radical retropubic prostatectomy: results from 1620 consecutive patients

OBJECTIVE

To report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function.

PATIENTS AND METHODS

From January 1992 to October 2006, one surgeon performed RRP with a nerve‐sparing technique where feasible. Men with erectile dysfunction before surgery, salvage RRPs, those not having a nerve‐sparing procedure, neoadjuvant or adjuvant therapy within 6 months of RRP and a follow‐up of <6 months were excluded from the analyses. Erectile function was evaluated by the surgeon when possible or by an annual questionnaire. Potency was defined as erectile function sufficient for intercourse with or without a phosphodiesterase‐5 inhibitor.

RESULTS

Of 619 men who had a bilateral and of 178 who had a unilateral nerve‐sparing RRP, 72% and 53%, respectively, were potent. When stratifying by age groups (≤49, 50–59, 60–69 and ≥70 years) potency rates were 86%, 76%, 58% and 37%, respectively. Potency was more common after bilateral than unilateral nerve‐sparing RRP in all age groups (P < 0.001). Age, bilateral nerve‐sparing (odds ratio 2.9) and surgeon experience were associated with potency in a multivariate analysis.

CONCLUSION

Careful patient selection and meticulous surgical technique are essential to achieve the right balance between cancer control and morbidity. The patient’s age, nerve‐sparing RRP and the surgeon’s experience were the significant predictors of return of potency after RRP.     

Time trends in prostate cancer surgery: data from an Internet-based multicentre database

Study Type – Therapy (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Treatment recommendations such as interdisciplinary guidelines are always based on scientific publications. However, high‐quality studies are very often focused on single‐centre series of selected cases. Health care research has failed to provide comprehensive information that describes the clinical reality of prostate cancer management even in smaller centres. This is a health care research study with 17 participating centres. Any prostate cancer centre can use the internet‐based database http://prostata‐ca.net , at no additional cost, to collect and analyze data for quality management, to conduct consecutive follow‐up assessments, and to compare their data with the averages recorded by all other centres. The database also enables time trend analysis of certain quality parameters in an annual comparison.

OBJECTIVES

? To report our experience with an Internet‐based multicentre database that enables tumour documentation, as well as the collection of quality‐related parameters and follow‐up data, in surgically treated patients with prostate cancer. ? The system was used to assess the quality of prostate cancer surgery and to analyze possible time‐dependent trends in the quality of care.

PATIENTS AND METHODS

? An Internet‐based database system enabled a standardized collection of treatment data and clinical findings from the participating urological centres for the years 2005–2009. ? An analysis was performed aiming to evaluate relevant patient characteristics (age, pathological tumour stage, preoperative International Index of Erectile Function‐5 score), intra‐operative parameters (operating time, percentage of nerve‐sparing operations, complication rate, transfusion rate, number of resected lymph nodes) and postoperative parameters (hospitalization time, re‐operation rate, catheter indwelling time). ? Mean values were calculated and compared for each annual cohort from 2005 to 2008. The overall survival rate was also calculated for a subgroup of the Berlin patients.

RESULTS

? A total of 914, 1120, 1434 and 1750 patients submitted to radical prostatectomy in 2005, 2006, 2007 and 2008 were documented in the database. ? The mean age at the time of surgery remained constant (66 years) during the study period. ? More than half the patients already had erectile dysfunction before surgery (median International Index of Erectile Function‐5 score of 19–20). ? During the observation period, there was a decrease in the percentage of pT2 tumours (1% in 2005; 64% in 2008) and a slight increase in the percentage of patients with lymph node metastases (8% in 2005; 10% in 2008). No time trend was found for the operating time (142–155 min) or the percentage of nerve‐sparing operations (72–78% in patients without erectile dysfunction). ? A decreasing frequency was observed for the parameters: blood transfusions (1.9% in 2005; 0.5% in 2008), postoperative bleeding (2.6%; 1.2%) and re‐operations (4.5%; 2.8%). The mean hospitalization time decreased accordingly (10 days in 2005; 8 days in 2008). The examined subcohort had an overall mortality of 1.5% (median follow‐up of 3 years).

CONCLUSIONS

? An Internet‐based database system for tumour documentation in patients with prostate cancer enables the collection and assessment of important parameters for the quality of care and outcomes. ? The participating centres show an improvement in the quality of surgical management, including a reduction of the complication rate.     

Angiomyolipomata: challenges,solutions, and future prospects based on over 100 cases treated

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

To examine the presentation, management and outcomes of patients with renal angiomyolipoma (AML) over a period of 10 years, at St George’s Hospital, London, UK.

PATIENTS AND METHODS

We assessed retrospectively 102 patients (median follow‐up 4 years) at our centre; 70 had tuberous sclerosis complex (TSC; median tumour size 3.5 cm) and the other 32 were sporadic (median tumour size 1.2 cm). Data were gathered from several sources, including radiology and clinical genetics databases. The 77 patients with stable disease were followed up with surveillance imaging, and 25 received interventions, some more than one. Indications for intervention included spontaneous life‐threatening haemorrhage, large AML (10–20 cm), pain and visceral compressive symptoms.

RESULTS

Selective arterial embolization (SAE) was performed in 19 patients; 10 received operative management and four had a radiofrequency ablation (RFA). SAE was effective in controlling haemorrhage from AMLs in the acute setting (six) but some patients required further intervention (four) and there was a significant complication rate. The reduction in tumour volume was only modest (28%). No complications occurred after surgery (median follow‐up 5.5 years) or RFA (median follow‐up 9 months). One patient was entered into a trial and treated with sirolimus (rapamycin).

CONCLUSIONS

The management of AML is both complex and challenging, especially in those with TSC, where tumours are usually larger and multiple. Although SAE was effective at controlling haemorrhage in the acute setting it was deemed to be of limited value in the longer term management of these tumours. Thus novel techniques such as focused ablation and pharmacological therapies including the use of anti‐angiogenic molecules and mTOR inhibitors, which might prove to be safer and equally effective, should be further explored.     

Single-institution experience with primary tumours of the male urethra

OBJECTIVE

To assess primary tumours of the urethra in males.

PATIENTS AND METHODS

We retrospectively reviewed our database from 1986 to 2006 for primary tumours of the male urethra; nine patients with primary tumours of the urethra were analysed and follow‐up information was obtained.

RESULTS

Three patients had tumours of the prostatic urethra, two of which had proliferating focal inflammation and one a low‐grade, superficial urothelial cancer. All patients were treated successfully with transurethral resection. Six patients had carcinoma of the bulbar or penile urethra, including two with previous local percutaneous radiotherapy for prostate cancer. All had primary surgical excision that was adapted to tumour location and extension. One patient had adjuvant chemotherapy after surgery. All but one patient remain recurrence‐free after a median follow‐up of 20 months.

CONCLUSION

Primary carcinoma of the male urethra is a rare entity. Previous radiotherapy might be a predisposing factor. Local surgical tumour control is essential for long‐term survival, but the extent of surgery depends on tumour location and stage. Multimodal therapy might be required to obtain an optimum oncological outcome.     

Narrow‐band imaging cystoscopy to evaluate the response to bacille Calmette‐Guérin therapy: preliminary results

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To evaluate whether narrow‐band imaging cystoscopy (NBIC) can identify bladder tumour suspected on follow‐up white‐light cystoscopy (WLC) after intravesical bacille Calmette‐Guérin (BCG) therapy, as BCG causes an intense reaction in the bladder, appearing as red lesions on WLC, which might be residual tumour or BCG‐induced inflammation.

PATIENTS AND METHODS

Sixty‐one patients with high‐risk non‐muscle‐invasive bladder tumours were evaluated 3 months after starting induction BCG therapy. All patients had abnormal erythematous lesions on WLC, suspected to be residual carcinoma in situ. After WLC, they were evaluated by NBIC, urine cytology and biopsy, followed by transurethral resection of all visible lesions.

RESULTS

Of the 61 patients, 22 (36%) had residual tumour. NBIC correctly identified tumour in 21 patients, but another 10 had unnecessary biopsy (NBIC positive, negative biopsy). Only one of 30 patients who had negative NBIC findings had tumour. NBIC outperformed urine cytology in detecting residual tumour after BCG therapy.

CONCLUSION

NBIC appears to better identify patients who have suspected residual tumour on follow‐up WLC at 3 months after BCG therapy.