Wednesday, April 30, 2014

Sunday, April 27, 2014

Wednesday, April 23, 2014

فيديوهات عملى الباثولوجى 2008) للدكتور الرائع (د/عبد الرحمن خليفة



وهى أفضل إسطواناته على الإطلاق
لأنها الوحيدة التى يستخدم فيها مؤشر
والأفضل جودة و الأطول وقتا
وتصلح لجميع الكليات
طلاب الفرقة الثالثة و طلاب الماجيستر

http://www.alltebfamily.com/vb/showthread.php?t=16051

http://ia600402.us.archive.org/24/items/alltebfamily.com_776/NormalKidney.wmv

How Much Do Doctors Make? Physician Compensation Report Has The Numbers

Medscape recently released a 2013 Physician Compensation report outlining the average earnings for physicians of different specialties, which specialties have seen a decline in pay, the differences in pay between men and women, and a range of more information. More than 24,000 doctors in 25 different specialties responded to Medscape’s annual survey.
http://www.medicaldaily.com/how-much-do-doctors-make-physician-compensation-report-has-numbers-278310

Tuesday, April 22, 2014

Embolization Shows Success in Benign Prostatic Hyperplasia Laird Harrison March 28, 2012


March 28, 2012 (San Francisco, California) — Prostatic artery embolization relieved the symptoms of benign prostatic hyperplasia in 2 studies presented here at the Society of Interventional Radiology 37th Annual Scientific Meeting.
The novel procedure, which has been tried in only 2 centers in the world, offers an alternative to transurethral resection of the prostate (TURP), with potentially fewer adverse reactions.
"This could mean that more men have a chance at getting their lives back," said researcher Francisco Cesar Carnevale, MD, PhD, professor and chief of the interventional radiology section at University of São Paulo in Brazil, in a statement.
"We're very happy," Dr. Carnevale told Medscape Medical News. "It's a feasible, effective, safe procedure."
In prostatic artery embolization, surgeons use microcatheters to place resin beads in the arteries that supply the prostate. The constricted blood flow causes the prostate to shrink, relieving pressure on the urethra. The procedure is done on an outpatient basis under local anesthesia.
A similar procedure has been used to treat uterine fibroids.
In one study, researchers from the University of São Paulo measured symptoms and objective changes in 11 men, 59 to 78 years of age (average, 68.5 years), with acute urinary retention due to an enlarged prostate. Follow-up ranged from 16 to 45 months.
At the time of treatment, the prostates ranged from 30 to 90 g (the normal male prostate weighs 20 to 25 g).
Magnetic resonance imaging (MRI) and ultrasound were used to study the exact anatomy of the prostate. The researchers analyzed 22 pelvic halves and saw a 30% reduction in mean prostate volume at 6 months.
All patients reported a high degree of satisfaction and an increased quality of life. Clinical success was achieved in 91% (10 of 11 patients).
"What makes this a difficult procedure is that there is varied anatomy," Michael Hamblin, MD, clinical assistant professor of radiology at the University of Illinois in Chicago, told Medscape Medical News. "You want to target specific branches and minimize potential complications. The most feared complication is impotence with any procedure done on the prostate."
About 5% of TURP patients suffer sexual dysfunction from the procedure, said Dr. Hamblin, who was not involved in the study.
Although none of the patients experienced complications during the procedure, the researchers warn that there is a risk for complications because the arteries involved have "varying origins, reduced diameters, tortuosity, and many anastomoses with other neighboring organs."
In a separate study, researchers from Saint Louis Hospital and the Faculdade de Ciências Médicas, both in Lisbon, Portugal, reported the results of embolization in 152 patients 47 to 85 years of age who had failed medical therapy. Of these, 18 had urinary retention and required indwelling catheters, and 8 had undergone previous partial prostatectomy.
The researchers reported technical success in 144 of 152 patients (94.7%), meaning that at least 1 prostatic artery was embolized.
The researchers reported clinical success at 3 months in 86 of 102 patients (84.3%), at 6 months in 60 of 74 patients (81.1%), at 12 months in 38 of 46 patients (82.6%), at 18 months in 13 of 16 patients (81.3%), and between 24 and 30 months in 7 of 10 patients (70%).
They documented 1 major complication: a 1.5 cm2 area of ischemia on the bladder wall that was surgically removal.
Minor complications included sensations of burning in the urethra, urinary infection, hematuria, hemospermia, balanoposthitis, rectorragies, inguinal hematoma and pain.
Dr. Hamblin and Dr. Carnavale have disclosed no relevant financial relationships.

FDA OKs New Device to Treat BPH Mark Crane September 13, 2013


The US Food and Drug Administration (FDA) today authorized the marketing of the UroLift system, the first permanent implant to relieve low or blocked urine flow in men aged 50 years and older with an enlarged prostate.
The UroLift system relieves the urine flow by pulling back the prostate tissue that is pressing on the urethra.
"The UroLift provides a less invasive alternative to treating [benign prostatic hyperplasia] than surgery," Christy Foreman, director of the Office of Device Evaluation at the FDA's Center for Devices and Radiological Health, said in a release. "This device also may offer relief to men who cannot tolerate available drug therapies."
The FDA's review of the UroLift system included data from 2 clinical studies of 274 men with BPH implanted with 2 or more UroLift sutures. Both studies showed that physicians successfully inserted UroLift in 98% of participants.
The studies also found a 30% increase in urine flow and a steady amount of residual urine in the bladder. Study participants answered validated questionnaires about their BPH-related symptoms and quality of life, reporting a decrease in symptoms and an increase in quality of life in the 2 years after treatment.
Minor adverse events reported included pain or burning during urination, blood in the urine, frequent or urgent need to urinate, incomplete emptying of the bladder, and decreased urine flow. Investigators did not report any serious device-related adverse events.
Severe BPH can lead to serious problems over time, such as strain on the bladder, urinary tract infections, bladder or kidney damage, bladder stones, and the inability to control urine (incontinence). Current treatment options to relieve symptoms associated with BPH include drug therapy or surgical procedures including removal of the enlarged part of the prostate.
The FDA reviewed the UroLift system through its de novo classification process, a regulatory pathway for some novel low-to-moderate risk medical devices that are not substantially equivalent to an already legally marketed device.
The UroLift System is manufactured by NeoTract Inc of Pleasanton, California.

In Prostate Hyperplasia, Combo Pill Slows Progress Kate Johnson April 18, 2014


STOCKHOLM — Outcomes were better when men with moderate symptoms of benign prostate hyperplasia were treated with dutasteride plus tamsulosin hydrochloride (Duodart, GlaxoSmithKline) than when they were monitored with watchful waiting, new research shows.
At each follow-up time point, "men who received lifestyle advice and alpha blocker therapy if they failed to improve had less symptom improvement than men who received combination therapy right from the start," said Claus Roehrborn, MD, professor and chair of urology at UT Southwestern Medical Center in Dallas.
First results from the CONDUCT trial, sponsored by GlaxoSmithKline, "suggest that in men with moderate symptoms but large prostates, combination therapy should be the treatment of choice," he told Medscape Medical News.
"Because 30% to 50% of elderly men will eventually develop prostatic enlargement, it's very important to see the long-term outcome of anything that's taken prophylactically," said Arnulf Stenzl, MD, from Tubingen Hospital in Germany
Dr. Stenzl is chair of the European Association of Urology (EAU) scientific abstract committee that selected the study as a late-breaking presentation here at the EAU 29th Annual Congress.
The multicenter, European, randomized, phase 4 study involved 742 men with a confirmed diagnosis of benign prostate hyperplasia and only moderate symptoms. Mean age was 66 years.
All men received lifestyle advice about caffeine and alcohol avoidance, fluid management, and bladder retraining. They were then randomized to watchful waiting (n = 373) or to daily treatment for 2 years with a single capsule containing the 5-alpha reductase inhibitor dutasteride 0.5 mg plus the alpha blocker tamsulosin 0.4 mg (n = 369)
Baseline characteristics were similar in the treatment and watchful waiting groups. Mean total serum prostate-specific antigen (PSA) levels ranged from 3.7 to 3.9 ng/mL, mean prostate volumes ranged from 51.0 to 52.6 cc, and the mean International Prostate Symptom Score (I-PSS) was "fairly modest," ranging from 12.9 to 13.2, Dr. Roehrborn reported.
When symptoms worsened, men in the watchful waiting group were stepped up to once-daily tamsulosin 0.4 mg. By the end of the trial, 61% of these men were receiving tamsulosin.
About 80% of subjects in each group completed the trial. More men in the treatment group than in the watchful waiting group discontinued therapy because of adverse events (36% vs 18%).
Mean change in IPSS from baseline — the primary end point — was significantly greater in the treatment group than in the watchful waiting group (5.4 vs 3.6; < .001). In addition, IPSS improved by at least 25% in significantly more men in the treatment group (73% vs 60%; P < .001).
At the end of the study, the rate of clinical progression of benign prostate hyperplasia was 43.1% lower in the treatment group than in the watchful waiting group (18% vs 29%; P < .001).
Similarly, improvements in hyperplasia symptoms and related quality of life were significantly greater the treatment group (P < .001).
Drug-related adverse events were more common in the treatment group than in the watchful waiting group (24% vs 10%), as were serious adverse events (10% vs 8%). The most common adverse events in the treatment and watchful waiting groups were retrograde ejaculation (5% vs 4%) and erectile dysfunction (8% vs 0%).
This study provided us with "information about the longer-term use of this therapy, the side-effect profile, and the impact this has on clinical progression," said Christopher Chapple, MD, consultant urological surgeon at Sheffield Teaching Hospitals, honorary professor at the University of Sheffield, and visiting professor at Sheffield Hallam University in the United Kingdom.
However, he told Medscape Medical News, "2 years is probably too short a time from which to draw too many meaningful conclusions."
The study was sponsored by GlaxoSmithKline. Dr. Roehrborn reports financial relationships with GlaxoSmithKline. Dr. Chapple reports financial relationships with Allergan, Astellas, AMS, GlaxoSmithKline, Lilly, ONO, Pfizer, and Recordati.
European Association of Urology (EAU) 29th Annual Congress: Abstract LBA1. Presented April 15, 2014.

Friday, April 18, 2014

Thursday, April 17, 2014

EAU 2014 - Active surveillance in 853 men with low and intermediate risk prostate cancer - Session Highlights Published on 14 April 2014


STOCKHOLM, SWEDEN (UroToday.com) - Dr. J. J. Aning presented an abstract on a cohort of 853 men (mean age of 65 years) with low- and intermediate-risk prostate cancer from Vancouver, Canada who were managed by active surveillance (AS). The primary aim of their study was to identify risk factors which lead to progression of prostate cancer while under AS. All men were 75-years-old or younger and had undergone restaging prostate biopsy, with at least 6 months of follow up. Their AS protocol involved 6 monthly PSA and DRE reviews in addition to rebiopsy of the prostate, with planned repeat biopsies every 2 years. Prostate cancer risk status was defined by National Comprehensive Cancer Network guideline criteria.
Mean PSA at diagnosis was 6.5ng/ml, with mean follow up of 5 years. Of the cohort, 50%, 27% and 23% were classified as very low-, low-, or intermediate-risk prostate cancer, respectively. Three hundred-nine men progressed to active treatment, most commonly due to grade progression at re-biopsy (62%), followed by patient choice (10%), and PSA progression (8%). Dr. Aning and colleagues reported actuarial probability of remaining on AS at 1, 2, 5, 8 years: 95%, 81%, 60%, and 47%, respectively. They reported a significant difference in the risk of progression to treatment between very low risk and other groups (p = 0.002), but not between low and intermediate risk groups (p= 0.481). On multivariate analysis, they determined that increasing number of positive biopsy cores at diagnosis and PSA density were significant predictors of progression to treatment (p= < 0.001). Negative prostate biopsy prior to diagnosis was found to be a significant negative predictor of progression to treatment (p=0.01). Of those treated, 4% (n=15) had biochemical recurrence. Overall survival of their AS cohort was 97%, with 1 death due to prostate cancer. Institutions continue to show evidence that AS is certainly a safe and viable option in select cohorts of men with diagnosis of prostate cancer.

Presented by J. J. Aning at the 29th Annual European Association of Urology (EAU) Congress - April 11 - 15, 2014 - Stockholmsmässan - Stockholm, Sweden
Vancouver Prostate Centre, Vancouver, Canada

Written by Reza Mehrazin, MD, medical writer for UroToday.com


Tuesday, April 15, 2014

Canadian content at GU-ASCO 2014: Highlights of research involving Canadian researchers


The 2014 Genitourinary Cancers Symposium (GU-ASCO 2014)
provided an opportunity for researchers from around the world to
present their research in a variety of fields, including prostate, renal
cell, penile, urethral and testicular cancers. Over the symposium’s 3
days, Canadian researchers were well-represented, with a number of
oral abstract podium presentations and many more research posters.
The following section provides brief summaries of some of the most
interesting work involving Canadians presented at GU-ASCO 2014 and
a listing of all the studies that included contributions from Canadian
researchers.
http://journals.sfu.ca/cuaj/index.php/journal/article/view/2015/1644

What is the best sequencing for sorafenib and sunitinib?


The Phase 3 Randomized Sequential Open-Label Study to
Evaluate the Efficacy and Safety of Sorafenib Followed by
Sunitinib Versus Sunitinib Followed by Sorafenib in the
Treatment of First-Line Advanced/Metastatic Renal Cell
Carcinoma (SWITCH) trial was the first study to prospectively
evaluate whether there or not there is an advantage to the
sequence of sorafenib followed by sunitinib (SO/SU) compared
to sunitinib followed by sorafenib (SU/SO). The primary results
of this study were presented at GU-ASCO 2014.1
The study, initiated in 2008, enrolled a total of 365 patients
with metastatic RCC (mRCC) who had not previously received
systemic therapy and were deemed to be unsuitable for cytokine
therapy. Patients were randomized 1:1 to receive sunitinib or
sorafenib. Patients were switched to the other therapy if they
experienced disease progression or intolerable toxicity. The
primary end point was the total progression-free survival (T-PFS)
from the time of initial randomization to confirmed progression
or death during second-line therapy. There were a number
of secondary end points presented as well, including overall
survival (OS), PFS in first-line treatment, PFS in second-line
treatment and objective response rate. Safety and tolerability
were also assessed.
At baseline, the 2 arms were well-balanced in terms of
demographics and disease characteristics, with no statistically
significant differences between treatment arms. At time of final

T-PFS analysis, there was no statistically significant difference
in T-PFS between treatment arms. The median T-PFS was 14.9
months for SU/SO and 12.5 months for SO/SU (hazard ratio
[HR] 1.01, p = 0.54). There was also no significant difference
between arms for OS (median 31.5 months for SO/SU and
30.2 months for SU/SO; HR 1.00, p = 0.49) (Fig. 1). However,

more patients in the SO/SU arm reached second-line therapy
compared to those in the SU/SO arm (57% vs. 42%, p < 0.01)
and the second-line PFS was significantly longer for the SO/
SU arm (median 5.4 months) compared to the SU/SO arm (2.8
months). The authors stressed that these results must be interpreted
with caution, however, due to the imbalance between
arms for patients initiating protocol-defined second-line therapy
and the fact that there was no randomization immediately
prior to the second line. There were also some differences in
tolerability profiles, with diarrhea and hand-foot skin reaction
being considerably higher in the SO/SU arm, while nausea and
stomatitis were more common in the SU/SO arm.
This study concludes that both sequences achieved comparable
PFS and OS with similar toxicity safety profiles, and further
illustrates the ongoing need to determine the best sequencing
strategies to optimize outcomes for mRCC patients.


WHAT’S NEW IN RENAL CELL CANCER RESEARCH


One of the major areas of research presented at the 2014 Genitourinary
Cancers Symposium (GU-ASCO 2014) pertained to the management
of renal cell cancer (RCC).

http://journals.sfu.ca/cuaj/index.php/journal/article/view/2014/1643

Enzalutamide


A pivotal study presented at GU-ASCO 2014 was the
Multinational Phase 3, Randomized, Double-Blind, Placebo-
Controlled Efficacy and Safety Study of Oral MDV3100 in
Chemotherapy-Naive Patients With Progressive Metastatic
Prostate Cancer Who Have Failed Androgen Deprivation
Therapy (PREVAIL) study investigating the utility of enzalutamide
in chemotherapy-naïve patients with CRPC.1 The study
population included a total of 1717 men, enrolled in 22 countries,
including Canada. The subjects were randomized 1:1
to enzalutamide capsules 160 mg/day (n = 872) or placebo
(n = 845). Concomitant steroids were allowed, but were not
required. The co-primary efficacy endpoints were overall survival
(OS) and radiographic progression-free survival (rPFS).
The trial was intended to continue until there were 765 deaths,
with a pre-planned interim analysis planned at 516 deaths (twothirds
of the final number of events).
The baseline characteristics were well-balanced in the 2
groups. Median age was 71 years in the placebo group and 72
in the enzalutamide group. Approximately two-thirds of patients
in each group were either asymptomatic or mildly symptomatic
at initial diagnosis and approximately two-thirds of each group

had an Eastern Cooperative Oncology Group (ECOG) performance
score of 0. Approximately 4% of each group were taking
corticosteroids at baseline.
At the time of the interim analysis, the Data Monitoring
Committee reported statistically significant benefits in both OS
and rPFS in favour of the enzalutamide arm. Because of these
findings, the trial was halted and unblinded at that time; the
planned interim analysis therefore became the trial’s final analysis.
Patients from the placebo arm were subsequently offered
treatment with enzalutamide.
The median duration of treatment among patients in the
enzalutamide arm was 16.6 months, almost 4 times higher than
that of the placebo group (4.6 months). At the time of the trial’s
discontinuation, 42.1% of enzalutamide patients remained on
treatment, as did 7.2% of those in the placebo arm.
Figures 1a and 1b show the curves for the 2 co-primary endpoints.
For OS, enzalutamide significantly reduced the risk by
29% (hazard ratio [HR] 0.706, 95% confidence interval [CI] 0.60
to 0.84, p < 0.0001). Enzalutamide also prolonged mean rPFS,
with an HR of 0.186 (95% CI 0.15 to 0.23, p < 0.0001). The
estimated mean rPFS was 3.9 months with placebo (95% CI 3.7
to 5.4) and was not yet reached (NYR) with enzalutamide (95%
CI 13.8 to NYR). For both co-primary endpoints, the results were
consistent across pre-specified subgroups (e.g., ECOG 0 or 1, age
above or below 75 years, presence or absence of visceral disease
and geographic regions). Overall, the subgroup analyses were
consistent with the benefit observed for the primary analysis of

OS and PFS. Subsequent therapies were used less frequently in
the enzalutamide arm than in the placebo arm: 56.7% of the placebo
group was subsequently treated with docetaxel and 45.6%
with abiraterone. In the enzalutamide group, 32.8% went on to
receive docetaxel and 20.5% received abiraterone.
Objective response rates (complete response [CR] plus partial
response [PR], defined as per RECIST 1.1 criteria) were 58.8%
(19.7% + 39.1%) for enzalutamide and 4.9% (1% and 3.9%) for
placebo (p < 0.0001). Enzalutamide delayed the median time to
chemotherapy by 17 months relative to placebo (p < 0.0001).
Serious adverse events (SAEs) were experienced by 32.0% of
patients in the enzalutamide group and 26.8% of the placebo
group. Discontinuations due to adverse events (AEs) were 5.6%
of the enzalutamide group and 6.0% of the placebo group. AEs
leading to death occurred in 4.2% of the enzalutamide group
and 3.8% of the placebo group. The most common AEs in both
groups were fatigue, back pain, constipation and arthralgia.

One seizure was reported in the placebo group, and 1 seizure
event was subsequently reported in the enzalutamide arm after
the date of data cut-off.
Overall, enzalutamide was well-tolerated compared to placebo;
it demonstrated minimal side effects, with an impressive
29% improvement in OS, and reduced the risk of rPFS by 81%
in those patients who have not received chemotherapy.
Another study of interest with enzalutamide presented at
GU-ASCO 2014 was the data from the extended follow-up
at 49 weeks of the open-label, single-arm, Phase 2 study in
67 patients with histologically-confirmed hormone-naive prostate
cancer requiring hormonal treatment and presenting with
non-castrate testosterone levels (>230 ng/dL), prostate-specific
antigen (PSA) >2 ng/mL, ECOG performance status of 0, and
life expectancy greater than 12 months.2 Enzalutamide was
associated with large reductions in PSA levels, which were
maintained over the duration of the 49-week analysis period
in this study. At week 49, the PSA response rate for all
patients entering the study was 80.6% (54/67) achieving a PSA
decrease of 80% or greater from baseline. Outcomes for all
endpoints at 40 weeks were consistent with those reported at 25
weeks, and no new safety signals were observed.



Approved novel agents targeting the androgen pathway


At GU-ASCO 2014, there was a significant body of research
presented involving several novel therapies targeting the androgen pathway for the treatment of castration-resistant prostate cancer (CRPC). This included several important studies involving two approved agents, the androgen-synthesis inhibitor abiraterone and the androgen-receptor antagonist enzalutamide.


Cite as: Can Urol Assoc J 2014;8(3-4Suppl2):S8-12. http://dx.doi.org/10.5489/cuaj.2013
Published online April 14, 2014.

What’s new in prostate cancer research? Highlights of GU-ASCO 2014



At the 2014 Genitourinary Cancers Symposium (GU-ASCO 2014),
international researchers presented an extensive array of research in
the field of prostate cancer treatment. The following pages provide a
summary of some of the most compelling results presented during the
3-day symposium.


http://journals.sfu.ca/cuaj/index.php/journal/article/view/2013/1642

Cost analysis of fixed-dose combination of dutasteride and tamsulosin compared with concomitant dutasteride and tamsulosin monotherapy in patients with benign prostatic hyperplasia in Canada


Canadian clinical guidelines recommend the use of the combination of tamsulosin and dutasteride for men with moderate/severe symptoms associated with BPH and enlarged prostate volume. This analysis, using a representational patient group, suggests that the FDC is a more cost-effective treatment option for BPH.
http://journals.sfu.ca/cuaj/index.php/journal/article/view/755/1493

Positive results from enzalutamide study on metastatic prostate cancer patients


The results of the Phase 3 Prevail Study on enzalutamide showed significant benefit to prostate cancer patients including delaying the progression of metastatic disease, reducing the risk of death and delaying the start of cytotoxic chemotherapy.
Enzalutamide did translate to significant overall survival to an unprecedented extent,” said Prof. Bertrand Tombal (BE) during the Late Breaking News segment of the concluding plenary session of the 29th Annual EAU Congress which ends today in Stockholm, Sweden.
Bertrand said the results of the main study and the European regional results of the phase 3 randomised PREVAIL study also has to be considered in a very rapidly changing treatment landscape when new prostate cancer drugs are emerging.
“Enzalutamide also has impact on other points such as time- to-PSA progression and has demonstrated a tolerability profile comparable to placebo,” he noted. “One of the clinical benefits is the ability to use this agent in second-line hormonal manipulation.”
The PREVAIL study involved 1,717 chemotherapy-naive met with asymptomatic or mildly symptomatic metastatic prostate cancer that progressed on androgen deprivation therapy (ADT). They were randomly assigned to receive 160 mg/day of enzalutamide or placebo in a double-blind fashion. More than 200 centres in 22 countries participated in the study which was stopped at the interim phase when results showed significant benefit.
Result showed that at the time of the interim analysis and after a median follow-up of 20 months, enzalutamide significantly reduced the risk of death by 29% (HR 0.706, 95% CI [0.60-0.84]; p < 0.0001) and reduced the risk of radiographic progression by 81% (HR 0.186, 95% CI [0.15-0.23]; p < 0.0001).Most common adverse events included fatigue, back pain, constipation, arthralgia and hypertension, among others.
“In both the full population and the European subpopulation treatment with enzalutamide significantly delayed the progression of metastatic disease, reduced the risk of death, and delayed the time to initiation of chemotherapy,” said Tombal, adding that the safety outcomes in the European subpopulation were consistent with those of full population.
“Enzalutamide added to ADT at progression provides meaningful clinical benefit to men with metastatic prostate cancer,” he said.

Welcome to the 30th Anniversary EAU Congress

For the 30th Anniversary EAU Congress, we return to Madrid after a successful congress in 2003. The IFEMA Congress Centre will be hosting us once more, as it is conveniently located near a major transit hub, and equipped with all the latest technology to ensure a successful scientific meeting.

Monday, April 14, 2014

Call for Abstract

3rd International Conference and Exhibition on 
Cell & Gene Therapy
October 27-29, 2014 Embassy Suites Las Vegas, USA
http://cellgenetherapy2014.conferenceseries.net/cfa.php

Sunday, April 13, 2014

Guidelines debate in favor of BCG maintenance 13 Apr 2014


Audience participation was an integral part of the Guidelines-dedicated Thematic Session 3 where the outcomes of pro and contra debates were revealed through voting. During the session Profs. Richard Sylvester (Brussels, BE) and George Thalmann (Bern, CH) discussed their views on BCG maintenance.
Prior to the debate, the audience was asked about their use of BCG, showing that 74% of the participants treat their patients with the drug. 12% reported they do not use it because of the side effects of the treatment.
After the presentations in which Sylvester demonstrated that BCG maintenance significantly reduces the risk of recurrence or cancer-related death and Thalmann questioned the treatment because of its severe side effects and the variable quality of TURBT preceding it, there was another round of voting.
It revealed that 29% of the voters would start using BCG maintenance after induction. Despite their opposing views during the presentation, Sylvester and Thalmann presented joint recommendations.
There remains a great need for additional, randomized studies, it is essential to perform a good TURBT before starting BCG treatment, and toxicity should be taken into account.

 

Saturday, April 12, 2014

EULIS session stresses diversity of stone disease 12 Apr 2014


The well-attended session of the EAU Section of Urolithiasis (EULIS) highlighted the heterogeneity of the condition by examining various aspects of stone disease. Gender aspects were discussed in relation to diagnosis, treatment, and prophylaxis. The advantages and disadvantages of percutaneous nephrolithotomy (PCNL) versus retrograde intrarenal surgery (RIRS) and multi-tract PCNL versus single-tract were also debated.
The traditional gender gap in the incidence of urolithiasis is closing now that more women are forming stones. Dr. Mehmet Özsoy (Vienna, AT) presented data which suggest that obesity may be the reason for the changing trend. He further mentioned that women have a greater risk of complications as a result of increased risk of urinary tract infections.
As diet adaptation is an effective prophylaxis in both sexes, Özsoy stressed the importance of increased public awareness of the ways to prevent stone formation with lifestyle changes and dietary adjustments.
Dr. Noor Buchholz (London, GB) argued that PCNL is the best option for any stone larger than 2 cm, rather than RIRS – which he said is less effective for larger stones. Improving the PCNL technique with flexible scopes and instrument minimisation will make PCNL the best treatment option for even smaller stones. Buchholz also predicted that technical innovations in RIRS will make it suitable for larger stones in the future.
Prof. Thomas Knoll (Sindelfingen, DE) and Dr. Cesare Scoffone (Turin, IT) discussed multi-tract PCNL. Knoll suggested that it is effective in experienced hands as a valid treatment option in very difficult cases, such as large staghorn stones.
Scoffone opposed this by saying that multiple tracts increase the risk of bleeding and renal scarring. He argued in favour of endoscopic combined intrarenal surgery (ECIRS), instead.
To conclude the session, Prof. Palle Osther (Fredericia, DK) presented the latest evidence-based guidelines. “Stone disease is a diverse disease for which you need both evidence and good clinical experience – neither is good enough on its own”, Osther said.

 

A.L. Burnett: We shouldn't stop looking for better options, just because we can use PDE5 inhibitors 12 Apr 2014


In this informative AUA lecture, Prof. Burnett addresses some of the most important concequences of urological surgery.

ESOU: Debating the best approach to radical prostatectomy and cystectomy 12 Apr 2014


One of the biggest themes during the meeting of the EAU Section of Oncological Urology (ESOU) was the comparison between robot-assisted radical prostatectomy and cystectomy to open surgery. Cost-effectiveness was an important factor in the discussion.
Dr. Bernardo Rocco (Milan, IT) made a case for robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer patients. He argued that RARP can prevent follow-up treatment and, with that, can be cost-effective. Stressing that it is important to take possible indirect costs into account next to direct costs, he showed that high-volume centres can reduce the costs of RARP.
Asst. Prof. Declan Murphy (Melbourne, AU) shared the experiences in Australia with RARP, as the incidence of prostate cancer in Australia and New Zealand is among the highest in the world. He noted a shift in the role of surgery in high-risk prostate cancer.
On the one hand it is becoming clearer that patients with localised disease do not benefit from prostatectomy and are recommended active surveillance or focal treatment, while on the other hand more high-risk patients are undergoing robot-assisted surgery.
Prof. Axel Heidenreich (Aachen, DE) took on the challenging task of tempering the enthusiasm for robot-assisted surgery. By pointing out that there are still no long-term data on RARP, no clear benefits to its effectiveness, no significant differences in quality of life of patients, and that it is not a cost-effective type of surgery, he argued in favour of open radical prostatectomy.
In the session about radical cystectomy, Prof. Richard Gaston (Bordeaux, FR) showed that robot-assisted radical cystectomy (RARC) can be performed safely because there is a lower risk of complications and patients generally have less blood loss. He further pointed out that the expertise of the surgical team is of utmost importance in any surgery.
Prof. Maurizio Brausi (Modena, IT) defended open radical cystectomy and proposed developing new techniques to make the procedure less invasive and comparable to robot-assisted surgeries. As radical cystectomy is mainly performed on older patients, it is important to minimise complications.
He went on to point out that there still is a lack of long-term data on RARC. Operating time is longer and there are complications inherent to this type of surgery, mainly equipment malfunction. As there is no significantly superior outcome and the costs of RARC are higher, Brausi stated that open radical cystectomy remains the golden standard for muscle-invasive bladder cancer.

Plenary Session 1: Courting controversy, providing answers 12 Apr 2014


EAU14’s first plenary session on “Andrology in Healthy Ageing” was everything a plenary session should be: informative and controversial, and combining the best of basic research with good clinical practice.
Prof. Wolfgang Weidner (DE) began with an overview of the current state of male infertility treatment. From the point of view of urologists specialising in andrology, the main problem may be how to obtain and select the best sperm, but there can be many other factors involved. He advocated a team-led approach involving not just urologists but, for example, counsellors, endocrinologists, oncologists, and other fertility specialists, depending on the individual’s circumstances.
Prof. Stefan Arver from the Karolinska in Stockholm (SE) reviewed the pros and cons of testosterone supplementation in the ageing male. His main message was that a diagnosis of hypogonadism is not a case of finding a testosterone level above or below a threshold, but that good clinical judgment has a huge role to play. Controversy was introduced by Dr. John Mulhall, from the Sloan Kettering Institute in New York (US), with his state-of-the-art lecture on the real or imagined dangers of testosterone supplementation. Dr. Mulhall stepped the audience through the recent media storm in the US and Europe, provoked by three papers in top-rated journals calling into question the safety of testosterone supplementation. As he said, this is a real and ongoing public health issue, with “patients requesting to stop therapy because of what they have read in the media”. Reviewing the methodologies of each paper, he showed how each displayed a degree of “bad science”. He also revealed that 25 medical societies have written to the editors of the journal which published the most recent paper, asking for a retraction because of methodological problems. We await this one with interest!
Dr. Maarten Albersen of the Laboratory of Experimental Urology in Leuven (BE) provided the basic science – which is on the verge of moving towards real clinical applications. For a detailed overview of his presentation on stem cell research in erectile dysfunction, see his article in the first edition of “EUT Congress News”.
Summarising the session, Co-Chair Professor Jens Sønksen said: “This was a stimulating session. As we have seen, there is an ongoing controversy on the testosterone use and cardiovascular disease (CVD). There have been 3 recent papers – 2 in the last couple of months alone – suggesting that testosterone use is linked to higher rates of CVD. These papers were all published in high-quality journals, but the work presented today really calls the methodologies of these papers into question. So we need new studies, we need really good RCTs to show whether there is any real problem or not.
The basic research is also very exciting. For years we have been discussing animal studies, and sometimes we have seemed very far away from translating these animal results into something which would really benefit patients. But now we seem to really be on the verge of moving forward. For a long time we have been producing abstracts rather than answers, now it looks like we may be moving towards real answers”.

B. Tombal: The future of trials in urology 12 Apr 2014


In this interview EORTC's current president talks about the current developments in the field of onco-urological trials. He stresses the need for a qualitative change in the way trials are designed to atteact practicing urologists to participate and offers examples of how this is already being done.

A quarter of men drop out of prostate cancer monitoring, casting doubt on safety of "active surveillance" 12 Apr 2014


A long-term follow up of prostate cancer patients shows that the option of monitoring slow-growing prostate cancer may not be as safe as thought, due to a quarter of men dropping out of the monitoring programme.
A long-term follow up of prostate cancer patients shows that the option of monitoring slow-growing prostate cancer may not be as safe as thought, due to a quarter of men dropping out of the monitoring programme.
Prostate cancer is the most common cancer in men, with a European incidence rate of 214 cases per 1000 men, outnumbering lung and colorectal cancer*. Research shows that with advancing age, most men are likely to have a cancer of the prostate, although for many the cancer will be so slow growing that it does not create a real problem. Recently there has been significant visibility given to the risk of prostate-cancer “overdiagnosis” – treatment when it is not justified by a serious health threat.
Given that treatment for prostate cancer involves either radiotherapy or major surgery, and that this can have significant side-effects, such as incontinence and impotence, there has been an increasing tendency to keep low-risk men under “active surveillance”; in other words not to treat the cancer immediately by surgery or radiotherapy, but to monitor the cancer regularly to see if it worsens. However, there have been very few studies showing how this surveillance works in real life.
Now a group of researchers from Baden in Switzerland have presented a long-term study to the European Association of Urology Congress in Stockholm which raises concerns regarding the safety of active surveillance. The study was based in a normal-sized hospital rather than in an academic medical centre, so is probably representative of how prostate cancer is followed up in the real world. This study followed 157 patients over a 13 period years active surveillance. After 13 years it was found that around a ¼ (28%) of all patients needed definitive treatment. Almost all of these men were cured from cancer. However, it was also found that about another ¼ (27%) of all patients did not show up to the recommended appointments – which actually is the key element of active surveillance.
These men did not reply to follow-up letters requesting ongoing check-up, thus dropping out of the active surveillance system.
As lead researcher Dr Lukas Hefermehl said:

“The limitation of this study is that this is not a huge sample, but nevertheless it is one of the best “real-world” samples we have with long-term data. I strongly believe that active surveillance is a good option for men who follow the recommended controls. But from our results it looks like there must be a significant number of men lost to follow up who will eventually develop a progressive disease; many of these men may even eventually die of prostate cancer. As Urologists we still remain responsible for these patients”.
The group also found that just 3 months after the initial diagnosis, 30 men (19%) refused a mandatory confirmation biopsy which could have ruled out a wrong interpretation of the first biopsy.
Dr Hefermehl continued:
We don’t know exactly what the reasons are. It may be that once the patient was told that this cancer is probably “not immediately threatening“ , he might downplay the importance of another test. On the other hand some men might have real concerns about the risk of there being a more severe cancer. Or it may be to do with the risk of incontinence or impotence after treatment, the idea of having cancer, a sense that nothing will really happen to them or it may be due to another reason which we just don’t know about”.
But the fact is that overall these findings leave us with a practical and ethical dilemma; we often recommend that men go onto an active surveillance programme, but these results indicate that more than a quarter of men will disappear from the system. We strongly believe that this “patient factor” must be taken into account for future active surveillance protocols”
Commenting, Professor Manfred Wirth (Technical University of Dresden), Treasurer and Executive Member, Communication, of the European Association of Urology said:
“This is very interesting and potentially controversial work, which is based on clinical practice in the real world. It shows that we may need a clearer understanding of the psychological factors which might get in the way of effective follow up in these points.“

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Updates 2014

Chronic Pelvic Pain 
LUTS
Male Sexual Dysfunction
Muscle-Invasive and Metastatic Bladder Cancer 
Neuro-Urology
Non-muscle-invasive Bladder Cancer 
Paediatric Urology
Penile Cancer
Priapism
Prostate Cancer 
Renal Cell Carcinoma
Upper Urinary Tract Urothelial Cell Carcinomas
Urolithiasis
Urinary Incontinence
Urological Infections
Urological Trauma


Individual Topics

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Upper Urinary Tract Urothelial Cell Carcinoma
Penile Curvature
Male Hypogonadism
Non-muscle Invasive Bladder Cancer
Reporting Complications
Bladder Cancer - Muscle invasive and metastatic
Primary Urethral Carcinoma
Prostate Cancer
Renal Cell Carcinoma
Testicular Cancer
Penile Cancer
Treatment of Non-neurogenic Male LUTS
Male Sexual Dysfunction
Male Infertility
Urological infections
Urinary Incontinence
Neuro-urology
Urolithiasis
Paediatric Urology
Urological Trauma
Pain Management
Chronic Pelvic Pain
Renal Transplantation
Lasers and Technology
Priapism
Robotic- and Single-site surgery in urology

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