Soc. Int. Urol. J., Volume 3, Issue 5 (September 2022) – 9 articles , Pages 291-355

Background: Approximately 15% to 20% of patients will experience disease recurrence following surgical removal of renal cell carcinoma. A range of pharmacological agents is prescribed for metastatic renal cell carcinoma, but there are trials testing whether these have an earlier role in the adjuvant setting. We aim to assess the efficacy of adjuvant systemic treatment following surgery in patients with renal cell carcinoma and to determine the most effective treatment. Methods: The protocol for this review was published in PROSPERO (CRD42021281588). We searched multiple databases up to August 2021. We included only randomized trials of patients with renal cell carcinoma that had been completely resected. We included patients with locoregional nodal disease if it was surgically removed, and excluded all cases of metastatic disease. We included all adjuvant systemic therapies that were commenced within 90 days of renal surgery. A network meta-analysis was performed using a frequentist approach. Results: A total of 13 studies with 8103 patients were included for analysis. Only pembrolizumab (HR 0.74; 95%CI 0.57 to 0.96) and pazopanib (HR 0.80; 95%CI 0.68 to 0.95) improved disease-free survival compared with observation. These 2 treatments were the 2 highest ranked comparisons with a P-score of 0.87 and 0.80. No agent improved overall survival. All agents increased the risk of severe adverse events compared with observation. Conclusions: Pembrolizumab and pazopanib were the only 2 adjuvant agents that improved time to disease recurrence compared with observation, with the former likely being the more efficacious. None of the treatments improved overall survival and almost all increased severe adverse events. Full article

There is a critical need to establish reference response rates following bladder-sparing therapies administered in the setting of bacillus Calmete-Guerin (BCG)-unresponsive non–muscle-invasive bladder cancer (NMIBC). We sought to determine the efficacy of different interventions in recent trials accruing patients fulfilling the strict BCGunresponsive definition established by the US Food and Drug Administration. We performed a systematic review and meta-analysis for clinical trials in the BCG-unresponsive disease space to include published and presented results. The primary endpoints were complete response rate for CIS±Ta/T1 tumors, recurrence-free rate for patients with papillary-only disease, and disease-free rate in studies enrolling both papillary CIS tumors (Ta/T1/CIS). I² was used for assessing heterogeneity. Eleven studies using 9 different therapeutic agents in a total of 909 patients with BCG-unresponsive NMIBC were identified. The resulting outcomes at 3, 6, and 12 months were 44%, 38%, and 25% complete response rate in CIS±Ta/T1 tumors; 73%, 58%, and 48% recurrence-free rate in papillary-only; and 48%, 22%, and 43% disease-free rate in combined Ta/T1/CIS, respectively. Relatively low levels of heterogeneity were observed amongst studies restricted to papillary-only or CIS±Ta/T1 tumors. Future randomized controlled studies are needed and will likely require stratification between papillary-only and CIS±Ta/T1 tumors. Full article

When the outcomes are equivalent to the open technique, conventional laparoscopy is a preferred surgical approach because of its minimal invasiveness. However, outcomes following laparoscopy depend on the surgeon’s expertise, and there is a significant learning curve to attain efficiency in complex reconstructing laparoscopic procedures. Robotic assistance bridges the gap between open and laparoscopic procedures and allows surgeons with limited laparoscopy experience to offer the benefits of minimally invasive surgery to their patients. While existing data do not show better outcomes with robot assistance compared with laparoscopy for most procedures, these studies are based on data from high-volume surgeons and centers. In reality, a significant number of surgeries are performed by low-volume centers and surgeons, and robotic assistance may enable them to offer benefits of minimally invasive surgery equivalent to those of higher volume centers since robotic assistance is associated with a shorter learning curve than laparoscopy. We review the data on the outcomes of robotic surgery for low-volume surgeons with a focus on centers and surgeons in Asia. Full article

Objectives: Many people are turning to alternatives to the conventional doctor-patient relationship, such as webbased search engines and video forums for their health care information. We undertook this study to investigate the quality of videos and information on renal cancer available on the streaming platform YouTube. Methods: We completed a search of YouTube (www.YouTube.com) in September 2021 with the term “kidney cancer.” The first 120 videos found which met the inclusion criteria (English speaking, duration greater than one minute, greater than 500 views, renal cancer addressed) were selected. We recorded information including duration, view count, likes, dislikes, comments, publisher, and author. The modified DISCERN tool and Global Quality Score (GQS) questionnaire were used to assess the quality of the included videos. The level of misinformation was assessed using a Likert 5-point scale. Descriptive statistics were used to analyse the collected data. A 2-sample t test was used to further analyse the quality assessment tool results before, during, and after 2016. Results: Most videos were published during or after 2016 (63.3%), were predominantly created in North America (77.5%), and were presented by health care professionals (60%). The median length of the videos was 4.23 (1.01 to 65.55) minutes, and the median number of views was 3087 (514 to 228,152). The median number of likes and dislikes was 24 and 5, respectively. The median modified DISCERN score was 3, the median GQS score was 3, and the grading for overall level of misinformation was moderate. Conclusion: The quality of information accessed from YouTube on kidney cancer is of a low to moderate overall standard with significant levels of misinformation. YouTube should not be used alone for educational purposes on renal cancer by patients or the public. It is best used in conjunction with information and advice from a medical practitioner and the health care system. Full article

Objective: To report changing practice in the management of intra-diverticular bladder tumours. Methods: We undertook a review of all intra-diverticular bladder tumours in our prospectively maintained institutional database. Results: A total of 28 patients (male = 27, female = 1) with a median age of 71 years (IQR 61 to 76) were diagnosed with intra-diverticular bladder tumours (IDBT) between March 2013 and February 2021. Fourteen had visible and 3 had non-visible haematuria, while 11 patients had lower urinary tract symptoms. Median axial diameter of the diverticula was 46 mm (IQR 35 to 69), and median neck diameter was 9 mm (IQR 7 to 11). All patients had CT-urography and 5 patients also had an MRI. Surgical treatment consisted of diverticulectomy (n = 11), diverticulectomy and ipsilateral ureteric reimplantation (n = 11), radical cystectomy and ileal conduit (n = 4), or radical cystectomy and orthotopic bladder (n = 2). Eleven patients had open procedures, and 17 had robotic assisted surgery. Final pathological stages were T0 (n = 2), Ta (n = 5), T1 (n = 7), T3a (n = 8) and T3b (n = 6). Twenty-four patients had urothelial carcinoma (including one nested variant and 4 with squamous differentiation) and 2 had small cell carcinoma. Three patients had neoadjuvant systemic chemotherapy, 2 had intravesical bacillus Calmette-Guerin (BCG) with mitomycin, and one had BCG monotherapy preoperatively. Five patients had adjuvant systemic chemotherapy while 7 had adjuvant intravesical therapies. Mean follow-up period was 37.8 months (±25.3). Mean recurrence-free survival was 61.5% (CI 45.7 to 77.4) and mean overall survival 71.6 % (CI 57.4 to 85.8). Ten patients (37%) died of cancer. Conclusion: Management of intra-diverticular bladder tumours is evolving. Bladder-sparing approaches are gaining popularity. Robot-assisted diverticulectomy is preferable as it reduces the morbidity resulting from treatment. Full article

Background: Lower urinary tract symptoms (LUTS) are commonly experienced among ageing males. The increasing prevalence of late-onset hypogonadism suggests a possible relationship between serum testosterone and severity of LUTS. This study examines the association between serum testosterone and severity of lower urinary tract symptoms among Malaysian men, as reflected by the International Prostate Symptom Score (IPSS). Method: A total of 163 men with LUTS were enrolled in a cross-sectional study in Hospital Canselor Tuanku Mukhriz, Malaysia. Full examination, IPSS, and serum total testosterone (TT) levels were evaluated. Categorical and continuous correlations were analyzed using chi-square test and age-adjusted Pearson’s partial correlation, respectively. Result: Mean age was 66.25 (SD = 7.05), with mean serum TT of 16.74 nmol/L (SD = 6.32). Twenty eight percent (n = 46) had low testosterone levels. Severity of LUTS (mild, moderate, severe) was not found to be dependent on TT status (normal, low, severely low), (χ² [4, N = 163] = 4.24, p = 0.37). Weak negative correlations between total IPSS and IPSS storage sub-score with serum TT levels were exhibited respectively (r = −0.17, p < 0.05; r = −0.17, p < 0.05). Conclusion: Among elderly Malaysian men, severity of LUTS and TT status were not found to be associated, despite a weak negative correlation between IPSS and serum testosterone levels. Nonetheless, with a high prevalence of hypogonadal ageing men, further research regarding serum testosterone measurement among this population may be valuable as part of a multimodal approach to treatment. Full article