Journal of Clinical Urology

Our objective was to analyze patterns of treatment for metastatic renal cell carcinoma (mRCC) (no treatment (NT), cytoreductive nephrectomy only (CN), systemic therapy only (ST), and both systemic and cytoreductive (ST+CN)), and correlate them with racial or socioeconomic factors.

Cases of mRCC from 2004–2015 were selected from the National Cancer Database. Our primary outcome was the temporal trend of treatment types. Secondary outcomes included the association of treatment with racial and socioeconomic factors. Logistical regression was performed.

In total, 40,372 patients with mRCC were identified. Treatment modalities included

37.0% NT, 13.9% CN only, 31.6% ST only and 17.5% ST+CN. From 2004–2015, NT decreased (53.4 vs. 32.1%, p < 0.001), CN alone decreased (18.1 vs. 12.1%, p < 0.001), ST alone increased (18.1 vs. 36.7%, p < 0.001) and ST+CN increased (10.3 vs. 19.1%, p < 0.001). On logistical regression, we found non-white races (odds ratio 1.29–1.73, p < 0.001), low-volume centers (hazard ratio (HR) 1.18, p < 0.001), no insurance (HR 2.29, p < 0.001) and low income (HR 1.24, p < 0.001) increased the likelihood of receiving NT.

More patients are receiving ST and ST+CN; however, racial and socioeconomic factors may affect the treatment patterns for mRCC, and the underlying cause of these health disparities is unknown.

2c6

Undescended testis (UDT) increases the risk of testicular cancer (TCa) development. Historical evidence suggests that malignant transformation of uncorrected UDT primarily results in seminomas, whereas mixed germ cell tumours predominate in corrected UDT; however, the risk of malignancy in the ‘normal’ contralateral testis is unclear. We investigated the contemporary Oxford TCa cohort to report the frequency of prior UDT and types of tumours developing in the prior UDT and normal contralateral testis.

A 607 patient contemporary TCa cohort within the Thames Valley Testicular Cancer database.

Of men with new TCa, 8% had a history of UDT. Of men with TCa and prior UDT, 61% developed seminomas, whereas 56% of men with TCa without previous UDT developed this subtype. Among men with prior UDT, 77% developed tumours in the UDT, whilst 23% developed TCa in the contralateral normal testis.

Seminoma was the most frequent malignancy following UDT, with a greater frequency than without prior UDT. Around one in four TCa patients with UDT developed contralateral tumours, emphasising the need for self-examination of both testes. Advice should be given to any patient with a history of UDT stressing the importance of ongoing self-examination of both testes.

Level 4.

Haemospermia is an alarming symptom for ordinary members of the public. The worry become greater as it has been described as a warning sign of a prostate cancer in the media.

The aim of the study was to identify the aetiological factors and outcome of haemospermia in a cohort of patients.

All patients with newly diagnosed haemospermia treated at the urology unit of Colombo South Teaching Hospital over a period of 5 years (2013–2018) constituted the study sample. Data related to demographics, symptomatology, clinical findings, investigations, treatment given and outcome during follow-up were recorded prospectively.

There were 94 men with haemospermia who sought treatment during the study period. Mean age was 43.7 years (range: 23–67, median = 41). Twenty-seven (29%) patients had clinical evidence of prostatitis and/or a positive seminal fluid culture. One patient each had prostate carcinoma, prostatic cyst, severe hypertension, sclerotherapy for haemorrhoids, post-chemotherapy and post-epididymectomy. The patient who had high blood pressure (220/150 mmHg) was found to have mesangio-proliferative glomerulonephritis. In 61 (65%) patients, there was no identifiable cause.

The majority of patients with haemospermia are aged < 45 years and have a benign aetiology. As haemospermia is self-limiting in the majority of cases, extensive investigations are unnecessary. Advanced and invasive tests should be confined to those with abnormal clinical findings, and to those with persistent or recurrent haemospermia.

Level IV.

To investigate the clinical effectiveness and cost-effectiveness of robotic technology in robotic-assisted radical prostatectomy in comparison with laparoscopic radical prostatectomy and open radical prostatectomy.

Cochrane, Medline and Embase databases were searched for randomised controlled trials to date on robotic-assisted radical prostatectomy versus laparoscopic radical prostatectomy and robotic-assisted radical prostatectomy versus open radical prostatectomy to assess clinical effectiveness. The British Association of Urology Surgeons database (2014–2016) and Cancer Research UK (2012–2014) were accessed in conjunction with media; keywords included: ‘Da Vinci’, ‘first robotic prostatectomy’, ‘hospital’ to estimate the cost-effectiveness of robotic-assisted radical prostatectomy in the National Health Service.

Functional outcome rates improved with robotic-assisted radical prostatectomy; this benefits the National Health Service financially although the clinical effectiveness may not meet the threshold of clinical importance. Regarding cost-effectiveness, approximately 12/43 (27.9%) centres achieved 150 robotic-assisted radical prostatectomies per year while 26/43 (60.4%) centres have managed to meet 100 robotic-assisted radical prostatectomies per year in 2014–2016. A national mean of 120–130 robotic-assisted radical prostatectomies per year for 2014–2016 was estimated.

The cost of robotic-assisted radical prostatectomy is adequately justified if a high volume of surgeries (>150) are performed in high volume centres by high volume experienced surgeons per year. This can be achieved by subsidising the cost of robotic technology, centralisation and establishing robotic training centres.

The National Health and Nutrition Examination Survey (NHANES) has demonstrated an upward trend in prevalence of kidney stones (KSs) in the past 30 years. We aim to report the current prevalence of KSs.

Research was based upon a cross-sectional analysis of response to the 2007–2014 NHANES. The prevalence of self-reported KS history was calculated using weights and design factors reported by NHANES. Four cycles of NHANES data were analyzed separately (2007–2014), and KS-prevalence trends in adult individuals for different age groups were compared. Analysis was performed using SAS ver.9.4.

The prevalence of KSs was 10.1% for the last 2013–2014 NHANES cycle. The highest prevalence of KSs was observed in males older than 60 years, at 17.8%, followed by males 40–59 years old at 12.6%. This trend changes in the 20–39-year-old age group, wherein females had a higher prevalence than males—7.5% for females compared to 4.5% in males. Females in the study showed a steady increase in KSs prevalence through the study cycles: 6.6% in 2007 to 9.5% in 2013 (p < 0.05). The increase in females ages 20 to 39, almost doubled in prevalence: 3.9 to 7.5%, from 2007 to 2013 (p < 0.05). Females older than 60 years of age have remained stable, with prevalence of 8.9% in 2007 to 9.8% in 2013. Males showed a slight decrease in prevalence from 2007 to 2014, from 12.7% in 2007 to 11.4% in 2014. Prevalence in males and females older than 60 years old were relatively stable.

Prevalence of KSs has remained stable in males and has increased in females. Females of child-bearing age showed the most significant increase. For this specific group, there has been a steady increase in the last seven years.

IV

Ureteroscopy (URS) is a procedure that is commonly performed by endourologists for stone surgery and other diagnostic and therapeutic indications. With stone disease becoming an increasing burden on the health economy, there is a clear incentive to perform URS as a day-case procedure.

This single-centre, single-surgeon study prospectively considered all patients for day-case rigid or flexible URS over a 12-month period, with the only exclusion criteria being an American Society of Anesthesiologists score greater than 3 or a lack of aftercare.

Sixty-six patients were included with 61 being discharged the same day of surgery, meaning a pure day-case rate of 92% and 30-day postoperative readmission rate of 6%.

This study suggests that URS should primarily be considered a day-case procedure whenever feasible.

2c

The purpose of this study was to investigate the prevalence and severity of the condition of lower urinary tract symptoms in Pakistani men, determine its predictors and assess its impact on the quality of life.

A cross-sectional, population-based study was conducted among men aged 30 years and over in three districts of Punjab province, Pakistan. The modified Urdu version of the International Prostate Symptom Score was used to assess the prevalence and severity of lower urinary tract symptoms. Individuals with total symptom score ⩾8 were considered as having lower urinary tract symptoms. The data were analysed using SPSS version 22. The chi-square test and Mann-Whitney U test were used to assess the difference among categorical and continuous variables, respectively. Moreover, binary logistic regressions were performed to determine the predictors of lower urinary tract symptoms.

The overall prevalence of lower urinary tract symptoms in our sample was 33.7%. The frequency of individuals having mild, moderate and severe lower urinary tract symptoms was 66.3, 30.3 and 3.4%, respectively. Storage symptoms were more common than voiding symptoms (35.6% vs 28.2%, respectively). Increasing age (one-decade interval age stratum), higher education levels, working status (currently not working), smoking, hypertension, diabetes and renal impairment were positive predictors of lower urinary tract symptoms. Moreover, the condition of lower urinary tract symptoms was associated with a significant reduction in an individual’s quality of life.

Around one-third of adult Pakistani men suffer from clinically relevant urinary symptoms, with lower urinary tract symptoms sufferers having poor quality of life as compared to non-sufferers. We recommend that the aging population should be made aware of conventional measures to mitigate mild urinary symptoms affecting their routine activities.

Level of evidence: 2c

To report on the performance and cost of a surgeon-led renal cancer specialist multidisciplinary team meeting at a high-volume centre.

Retrospective analysis of 1500 consecutive cases discussed from 2 September 2015 onwards. Performance was assessed as the number of cases where a clinical recommendation was made. The cost per meeting, discussion and patient were calculated using the mid-point of pay band attributable to the attendees (National Health Service pay scales 2015).

Over 34 meetings, 1500 discussions occurred (933 patients: 61.7% male; mean age 63.8). Above a one-quarter of discussions (n = 399, 26.6%) were new referrals. Each patient’s case was discussed a mean of 1.6 times, the majority being discussed once (n = 563, 60.3%). In 93.3% of discussions, a clinical recommendation was made. Only 100 discussions (6.7%) were deferred due to incomplete clinical information. A total of 11.1% (n = 166) cases were discharged. The average costs were: £141,901 per year, £2729 per meeting, £62 per case discussed and £99 per patient.

One discussion was usually sufficient to decide management; deferral was uncommon; and, given the low discharge rate, referrals seemed appropriate. The cost per patient was modest, and represented good value in providing a focused and shared clinical decision-making pathway for renal cancer patients.

2C