European Urology Supplements - Articles in Press

Current Value of Neoadjuvant Chemotherapy Prior to Cystectomy - Corrected Proof

Marko Babjuk — 2010-03-08

Abstract: Context: Radical cystectomy with a pelvic lymph node dissection is considered the most effective treatment option today for patients with muscle-invasive bladder cancer. Unfortunately, in spite of some progress, disease-specific survival rates after cystectomy have not dramatically changed in the last few decades. The significant risk of distant failure indicates that additional systemic treatment is mandatory.Objective: The primary objective of the review was to summarize the data about the benefit of neoadjuvant systemic chemotherapy before cystectomy for muscle-invasive bladder cancer.Evidence acquisition: The papers evaluating cystectomy cohorts were analyzed including a thorough analysis of treatment failures. The papers presenting prospective randomized trials and meta-analyses on neoadjuvant chemotherapy in bladder cancer were critically reviewed.Evidence synthesis: The rationale for chemotherapy before cystectomy is to treat micrometastases beyond the margins of local therapy already present at the time of diagnosis of invasive bladder cancer. Results of prospective randomized trials indicate survival benefit after neoadjuvant platinum-based combination chemotherapy. To improve the interpretation of data from prospective randomized trials, several meta-analyses were conducted. The most recent meta-analysis, published in 2005, evaluated the individual data from 3005 patients enrolled in 11 prospective controlled trials that compared neoadjuvant chemotherapy plus local treatment with local treatment alone. The data comprised 98% of all patients from known eligible randomized controlled trials. The analysis found significant survival benefit associated with platinum-based combination chemotherapy. It was equivalent to a 5% absolute improvement in overall survival (p=0.003) and a 9% improvement in disease-free survival (p<0.0001) at 5 yr.Conclusions: Radical cystectomy with pelvic lymph node dissection remains the standard treatment for muscle-invasive bladder cancer. The quality of surgery is essential for optimal treatment results. The data from prospective randomized trials and meta-analyses provide support for preoperative application of platinum-based combination chemotherapy in all patients.Take Home Message: The data from prospective randomized trials and meta-analyses provide support for platinum-based neoadjuvant combination chemotherapy before cystectomy in patients with muscle-invasive bladder cancer.

Preventing Complications in Robotic Prostatic Surgery - Corrected Proof

Rafael Sanchez-Salas, Vincent Flamand, Xavier Cathelineau — 2010-03-08

Abstract: Context: The urologic community has embraced robot-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) as a surgical therapeutic approach to localised prostate cancer (PCa). Safety, efficacy, and potential complications of RALP should be clearly known and emphasised in order to improve outcomes.Objective: To provide an overview of the prevention and reduction of complications in RALP to aid the understanding of the multivariable nature of a surgical procedure incorporating highly developed technology.Evidence acquisition: The present manuscript is based on a presentation on the prevention of complications in robotic prostatic surgery held at the European Association of Urology Section of Oncological Urology meeting in Vienna, Austria, in January 2010. The scope of this article is such that no attempt has been made to include all available evidence on the topic but rather a selection based on practical considerations. Experience with RALP gained at the Institut Montsouris is also reflected in the body of the manuscript.Evidence synthesis: Despite the lack of standardisation when talking about complications, RALP seems to be at least equivalent to laparoscopic radical prostatectomy, and recently, it appears to provide even better results. To prevent complications, RALP should be considered in its entirety from patient evaluation to postoperative care, not just the surgery itself. The surgeon remains the first actor, and no place is left for improvisation. Thus, every step of the procedure must be perfectly understood and mastered. One must remember that years of training stand behind these high levels of control and technique.Conclusions: Prevention and management of complications in RALP require a high level of team expertise. Perfect standardisation of the procedure and the communication of the procedure's results are mandatory to lowering the incidence of complications and to facilitating its diffusion to the urologic community.Take Home Message: Improvements in outcomes for robot-assisted laparoscopic prostatectomy must be based on a comprehensive analysis of every such procedure to reduce potential complications. The undeniable evolution of radical prostatectomy must be supported by an objective evaluation and report of the possible undesirable events associated with surgery. Prevention of complications should be addressed through an action network aiming to improve patient results.

Challenging the EAU Guidelines: Role of Biopsy and Management of Small Renal Tumours - Corrected Proof

Luis Martinez-Piñeiro, Mario Alvarez Maestro — 2010-03-08

Abstract: Context: The European Association of Urology (EAU) guidelines on renal cell carcinoma (RCC) were reviewed for the debate, “Challenging the EAU Guidelines,” held during the European Society of Oncological Urology meeting in 2010.Objective: Our aim was to review the role of biopsy and the management of small renal tumours.Evidence acquisition: The EAU guidelines updated March 2009 were reviewed and compared critically with some of the largest series of renal tumours published in the English literature during the last 5 yr.Evidence synthesis: The EAU guidelines conclude that tumour subtype has no prognostic information. This statement is based on a single manuscript with two important drawbacks: First, there was no centralised slide review, and second, 25% of the patients already had metastases when diagnosed, which does not represent the actual patient population that undergoes surgery nowadays. However, the EAU guidelines conclude there is only a limited indication for fine-needle biopsy of renal masses. But the literature review shows that fine-needle biopsy can provide an accurate differentiation between malignant and benign tissue in >90% of cases with negligible side-effects.Conclusions: Tumour histology seems to be independently associated with survival in patients who undergo surgery for RCC even after controlling for widely accepted factors influencing progression. Because small incidentally discovered renal tumours may be benign in a substantial percentage of patients, biopsy to confirm malignancy is important in the diagnostic and therapeutic algorithm. It also may be very useful to guide less aggressive treatment options in tumours with less aggressive features. The EAU guidelines should be modified accordingly.Take Home Message: Biopsy to confirm malignancy is important in the diagnostic and therapeutic algorithms of small renal tumours because tumour histology is independently associated with survival and because small renal tumours may be benign in a substantial percentage of patients.

Role of Chemotherapy and Immunotherapy for Urinary Upper Tract Cancer - Corrected Proof

Christian Pfister — 2010-03-08

Abstract: Background and Objective: The gold standard for open radical nephroureterectomy is currently being challenged by minimally invasive procedures for upper tract tumour management. A nephron-sparing approach may be proposed in patients with an anatomic or functionally solitary kidney, bilateral disease, significant chronic renal insufficiency, or medical comorbidities in whom major surgical procedure would be poorly tolerated.Material, Methods and Results: Local recurrence has been observed in 65% of patients with endoscopically treated upper tract tumours, with an average time to recurrence of <10 mo. Adjuvant topical immunotherapy or chemotherapy agents have been reported in the literature for treatment and prophylaxis of transitional cell carcinoma. Two major techniques are usually recommended for the administration of mitomycin C (MMC) and bacillus Calmette-Guérin (BCG): perfusion through a percutaneous nephrostomy tube or by retrograde reflux from the bladder with an indwelling double-J stent in the Trendelenburg position. BCG therapy has been reported to provide cure in approximately 50% of renal units with carcinoma in situ; however, papillary and solid tumour recurrences of the urinary upper tract cannot be prevented with BCG therapy. Adjuvant therapy is considered safe, with no systemic side-effects resulting from perfusion with MMC as topical therapy following endoscopic resection of upper urinary tract carcinoma. In contrast, up to 25% of patients may have granulomatous involvement of the urinary tract after BCG administration.Conclusion: The efficacy and safety of this conservative approach warrants further evaluation, as long-term follow-up is necessary to confirm previously reported oncologic data. Moreover, adjuvant therapy may be proposed with the patient's consent, as it requires a strict ureteroscopic surveillance protocol.Take Home Message: No randomized trial specifically addressing the effectiveness of topical immunotherapy or chemotherapy has been reported for adjuvant treatment in conservative management of upper tract tumours. Currently, adjuvant therapy may be proposed, with the patient's consent, in addition to a strict ureteroscopic surveillance protocol.

Recent Developments in Research and Treatment of Testicular Cancer: Highlights from Oncologic Congresses in 2009 - Corrected Proof

Ilker Tinay, Levent Türkeri — 2010-03-08

Abstract: Objectives: This paper summarizes new findings on testicular cancer presented at the European Society for Medical Oncology and American Society of Clinical Oncology annual meetings in 2009.Methods: Data were discussed during the seventh meeting of the European Association of Urology Section of Oncological Urology in January 2010. Selection of data was based on expert experience.Results: An important molecular study on metastasized and nonmetastasized seminoma tissues showed that presence of metastases can be predicted with 100% specificity based on an 85-gene expression signature. Invasion of the rete testis and age (<30 yr) represented high-risk factors for patients with clinical stage I testicular seminoma, independent from the treatment selected. Long-term results (8 yr) of standard bleomycin (B), etoposide (E), and cisplatin (P) therapy for good prognosis germ cell tumors (GCTs) concluded a continuing survival benefit, with 3B90E500P proving itself as the standard of care. A new individualized treatment protocol based on tumor marker decline in metastatic nonseminomatous germ cell testicular cancer is highly encouraging in all risk groups. But a phase 3 randomized trial with administration of front-line high-dose chemotherapy in poor-prognosis GCTs did not improve treatment outcome. The 20-yr experience with two cycles of PEB showed that late toxicity is rare; the two principal effects of the treatment were higher triglyceride and lower testosterone levels in this group of patients.Two important studies investigated surgery versus surveillance for postchemotherapy residual masses in patients with metastatic nonseminomatous GCTs (NSGCTs). They both concluded that residual masses <15mm after primary chemotherapy for metastatic NSGCT may be managed without surgery; no clear conclusions are drawn for larger masses, and further studies are needed. Retrospective analysis of complications of postchemotherapy residual tumor resection showed that full bilateral resection is not necessary in all cases and resection field should be adapted to the localization of disease and size of the mass to minimize complications.The popular question of whether to use open or laparoscopic surgery for retroperitoneal masses remained unanswered. The results of a short follow-up study (15 mo) favored open surgery for better operating time and lower complication rate and laparoscopic surgery for shorter hospital stay. There was no difference in the rate of distant metastases.Conclusions: New data presented at these meetings may contribute to improved management of testicular cancer.Take Home Message: The 2009 meetings of the European Society for Medical Oncology and the American Society of Clinical Oncology held interesting presentations on testicular cancer. Information about better methods of diagnosis and treatment through research followed by proper scientific distribution of this information should aid urologists and oncologists in management of testicular cancer patients.

REMOVED: Evaluation of Vena Caval Tumour Thrombus with Intraoperative Ultrasound - Corrected Proof

2006-05-01

This article has been removed, consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.

WITHDRAWN: Corrigendum to: “How Good do Current LHRH Agonists Control Testosterone? Can this be Improved with Eligard®?” [European Urology Supplements 4/8 (2005) 1–41] - Corrected Proof

Bertrand Tombal, Richard Berges — 2006-02-10

The publisher regrets that this article is an accidental duplication of an article that has been published in Eur Urol 49 (2006) 937, doi:10.1016/j.eururo.2006.03.032. The duplicate article has therefore been withdrawn.