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Background Discordance exists between scientific impact and media attention. Altmetrics are non-traditional measures of impact which are composite scores that include social media and traditional media sharing of an article. Objective To assess whether a correlation exists between newsworthiness (Altmetric score) and the scientific impact markers such as citation analysis, impact factors and levels of evidence. Materials and Methods The top 5 most cited articles for the year 2014 and 2015 from the top 10 ranking urology journals (scientific impact group) were identified. The top 50 articles each in 2014 and 2015 were identified from Altmetric support based on media activity (media impact group). We determined the number of citations that these articles received in the scientific literature, and calculated correlations between citations with Altmetric scores. Results In the scientific impact group, the mean number of citations per article was 37.6, and the most highly cited articles were oncology guidelines. The mean Altmetric score in these articles was 14.8, There was a weak positive correlation between citations and Altmetric score (rs = 0.35, 95% CI 0.16-0.52, p

Objective To evaluate the effects of a web-based clinical pathway (WCP) for radical nephrectomy on patient care, and to compare the effects with those of a paper-based clinical pathway (PCP). Patients and methods Patients with renal cell carcinoma and who underwent radical nephrectomy were enrolled into the study. The results of using the WCP for radical nephrectomy from July 2000 to August 2001 were compared with those using the PCP between May 1999 and June 2000. The mean hospital stay, average admission charges, six quality indicators, and the advantages of the WCP were determined. Results Using a WCP for radical nephrectomy reduced the hospital stay and admission charges by as much as the PCP. A similar number of patients had variances from the WCP as with the PCP ( P = 0.407), but the number of undetected variances and the variance detection time in the WCP were significantly less ( P = 0.0193 and 0.0162). Implementing a WCP also improved the quality of care by as much as a PCP. Conclusions Using a WCP for radical nephrectomy can improve health outcomes by reducing the hospital stay and admission charges, and by improving the quality of care by as much as a PCP. Furthermore, the WCP was more accurate and faster than the PCP in detecting variances.

Objective The aim of the paper is to provide an overview of intraoperative sampling methods for frozen section (FS) analysis and of surgical techniques for a secondary neurovascular bundle (NVB) resection, as the method of surgical margin (SM) sampling and the management of a positive SM (PSM) at the nerve-sparing (NS) area are under evaluated issues. FS analysis during radical prostatectomy (RP) can help to tailor the plane of dissection based on cancer extension and thus extend the indications for NS surgery. Evidence acquisition We performed a PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science, Cochrane Library, and Elton B. Stephens Co. (EBSCO)host search to include articles published in the last decade, evaluating FS analysis in the NS area and surgical attempts to convert a PSM to a negative status. Evidence synthesis Overall, 19 papers met our inclusion criteria. The ways to collect samples for FS analysis included: systematic (analysing the whole posterolateral aspect of the prostate specimen, i.e., neurovascular structure-adjacent frozen-section examination [NeuroSAFE]); magnetic resonance imaging (MRI)-guided (biopsies from MRI-suspicious areas, retrieved by the surgeon in a cognitive way); and random biopsies from the soft periprostatic tissues. Techniques to address a PSM in the NS area included: full resection of the spared NVB, from its caudal to cranial aspect, often including the rectolateral part of the Denonvilliers' fascia; partial resection of the NVB, in cases where sampling attempts to localise a PSM; incremental approach, meaning a partial or full resection that extends until no prostate tissue is found in the soft periprostatic environment. Conclusions There is no homogeneity in prostate sampling for FS analysis, although most recent evidence is moving toward a systematic sampling of the entire NS area. The management of a PSM is variable and can be affected by the sampling strategy (difficult localisation of the persisting tumour at the NVB). The difficult identification of the exact soft tissue location contiguous to a PSM could be considered as the critical point of FS analysis and of spared-NVB management.

To review the emerging role of technical and non-technical simulation in urological education and training. A review was conducted to examine the current role of simulation in urology training. A PUBMED search of the terms 'urology training', 'urology simulation' and 'urology education' revealed 11,504 titles. Three hundred and fifty-seven abstracts were identified as English language, peer reviewed papers pertaining to the role of simulation in urology and related topics. Key papers were used to explore themes. Some cross-referenced papers were also included. There is an ongoing need to ensure that training time is efficiently utilised while ensuring that optimal technical and non-technical skills are achieved. Changing working conditions and the need to minimise patient harm by inadvertent errors must be taken into account. Simulation models for specific technical aspects have been the mainstay of graduated step-wise low and high fidelity training. Whole scenario environments as well as non-technical aspects can be slowly incorporated into the curriculum. Doing so should also help define what have been challenging competencies to teach and evaluate. Dedicated time, resources and trainer up-skilling are important. Concurrent studies are needed to help evaluate the effectiveness of introducing step-wise simulation for technical and non-technical competencies. Simulation based learning remains the best avenue of progressing surgical education. Technical and non-technical simulation could be used in the selection process. There are good economic, logistic and safety reasons to pursue the process of ongoing development of simulation co-curricula. While the role of simulation is assured, its progress will depend on a structured program that takes advantage of what can be delivered via this medium. Overall, simulation can be developed further for urological training programs to encompass technical and non-technical skill development at all stages, including recertification.

Key Messages Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) can be bothersome and negatively impact on a patient's quality of life (QoL). As the prevalence of LUTS/BPH increases with age, the burden on the healthcare system and society may increase due to the ageing population. This review unifies literature on the burden of LUTS/BPH on patients and society, particularly in the UK. LUTS/BPH is associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning, and through its negative impact on QoL for patients and partners. LUTS/BPH is often underdiagnosed and undertreated. Men should be encouraged to seek medical advice for this condition and should not accept it as part of ageing, while clinicians should be more active in the identification and treatment of LUTS/BPH. To assess the burden of illness and unmet need arising from lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH) from an individual patient and societal perspective with a focus on the UK. Embase, PubMed, the World Health Organization, the Cochrane Database of Systematic Reviews and the York Centre for Reviews and Dissemination were searched to identify studies on the epidemiological, humanistic or economic burden of LUTS/BPH published in English between October 2001 and January 2013. Data were extracted and the quality of the studies was assessed for inclusion. UK data were reported; in the absence of UK data, European and USA data were provided. In all, 374 abstracts were identified, 104 full papers were assessed and 33 papers met the inclusion criteria and were included in the review. An additional paper was included in the review upon a revision in 2014. The papers show that LUTS are common in the UK, affecting ≈3% of men aged 45–49 years, rising to >30% in men aged ≥85 years. European and USA studies have reported the major impact of LUTS on quality of life of the patient and their partner. LUTS are associated with high personal and societal costs, both in direct medical costs and indirect losses in daily functioning. While treatment costs in the UK are relatively low compared with other countries, the burden on health services is still substantial. LUTS associated with BPH is a highly impactful condition that is often undertreated. LUTS/BPH have a major impact on men, their families, health services and society. Men with LUTS secondary to BPH should not simply accept their symptoms as part of ageing, but should be encouraged to consult their physicians if they have bothersome symptoms.

Objective To retrospectively review recent publications describing novel procedures/techniques, and describe the Institutional Review Board (IRB)/ethics approval process and potential ethical dilemmas in their reporting. Materials and Methods We searched PubMed for papers about innovative or novel procedures/techniques between 2011 and August 2012. A query of titles/abstracts in the Journal of Urology, Journal of Endourology, European Urology, BJU International, and Urology identified relevant papers. These results were reviewed for human studies that described an innovative technique, procedure, approach, initial series, and/or used new technology. Results In all, 91 papers met criteria for inclusion; 25 from the Journal of Endourology, 14 from the Journal of Urology, nine from European Urology, 15 from the BJU International and 28 from Urology. IRB/ethics approval was given for an experimental procedure or database in 24% and 22%, respectively. IRB/ethics approval was not mentioned in 52.7% of studies. Conclusions Published IRB/ethics approvals for innovative techniques are heterogeneous including database, retrospective, and prospective approvals. Given the concept that innovations are likely not in the legal or ethical standard of care, strong consideration should be given to obtaining IRB/ethics approval before the actual procedure, instead of approval to merely report database outcomes.

What's known on the subject? and What does the study add? Penile shortening after total prostatectomy has been consistently reported, but most studies are small. BAUS has incorporated penile shortening into their patient information leaflets, but claims it is attributable to an anatomical alteration alone. No other organization even mentions penile shortening in their advice. Our study shows that a true, and at least partially reversible, penile shortening occurs in a significant proportion of patients after total prostatectomy. The cause of the shortening is largely physiological and interlinked with the processes leading to erectile dysfunction. OBJECTIVE • To establish an evidence base to guide consenting for treatment of organ-confined prostate cancer with regard to penile shortening. MATERIALS AND METHODS • We performed literature searches using the EMBASE, MEDLINE, AHMED and PsycINFO databases up to October 2011, looking for articles relating to surgical treatment of prostate cancer and penile shortening and articles relating to radiotherapy for prostate cancer and penile shortening. We also looked at further references in the papers identified. RESULTS • We found 16 original papers and three review articles with measurements of penile shortening after total prostatectomy (TP). • Penile shortening was generally considered in conjunction with erectile dysfunction (ED). • Three further articles address psychological and consent issues. • We found two articles regarding penile shortening after radiotherapy for prostate cancer. CONCLUSIONS • There is no doubt that TP leads to penile shortening in some patients, but the mechanism remains debatable. • Given current evidence, it is likely that several factors contribute and early penile rehabilitation for ED, by any method, appears to positively influence the changes leading to penile shortening. • We advise explicit mentioning of penile shortening in the consent process for TP and potentially also for radiotherapy for prostate cancer. We also advise early penile rehabilitation to improve the patient's own body image and, in turn, quality of life, even in patients who do not seek treatment specifically for ED. The choice of treatment method should be left to the patient.

Study Type – Prognosis (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Prognostic factors such as serum PSA, tumor T stage, and Gleason grading are commonly used to predict disease progression and mortality in prostate cancer and to guide treatment decision-making. These markers are combined to define risk strata that are commonly accepted in practice. Despite the assignment of patients to a specific risk stratum (e.g. intermediate-risk disease), however, within-stratum survival duration varies considerably, suggesting that many other factors, including lymphovascular invasion (LVI) may influence prognosis. LVI is currently a recognized prognostic factor in the management of some cancers (e.g. in early-stage breast cancer) and prostate cancer is known to spread via lymphatic channels. Furthermore, the reporting of microscopic lymphovascular invasion is now considered part of the standard pathologic report of prostatectomy specimens. Nevertheless, scientific studies in this area have produced conflicting conclusions regarding the utility of LVI as a prognostic indicator in prostate cancer. This paper provides a comprehensive review and synthesis of the recent literature. Although a number of studies examining the role of LVI as an independent prognostic factor for biochemical recurrence in prostate cancer have been reported, the characteristics, quality and results of these studies vary considerably. The value of using LVI as a prognostic factor in prostate cancer remains unclear. This study provides a systematically-performed synthesis of the results of recent research including lymphovascular invasion (LVI) in the multivariate analyses of potential prostate cancer prognostic factors. Not only do we report on the results of these studies, we assess the heterogeneity of the study populations, disease characteristics, and quality of the studies. Ultimately, we determined that meta-analysis of the existing data is not possible, and thus, there is no ‘best estimate’ of the strength of association between LVI status and disease recurrence after prostatectomy. Most studies, but not all, reveal a weak or statistically insignificant association between LVI status and recurrence. We therefore conclude with a recommendation to clinicians that they should not overweight the importance of LVI status on clinical prognostication. The use of LVI status as a strong predictor of clinical outcomes is not recommended. OBJECTIVES • To synthesize the results of studies including lymphovascular invasion (LVI) in the multivariate analyses of potential prostate cancer prognostic factors. • To determine the role of LVI as an independent prognostic factor for biochemical recurrence in prostate cancer. PATIENTS AND METHODS • We performed a comprehensive systematic literature review of studies examining the association between LVI in prostatectomy specimens and prostate cancer recurrence. • Ovid MEDLINE, Embase, Web of Knowledge, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects (DARE) and Google Scholar were searched from January 2000 to February 2009. • The primary outcome of interest was biochemical recurrence measured by serum prostate specific antigen (PSA). RESULTS • One thousand two hundred and forty-eight papers met our search criteria. Of these, 19 articles meeting our selection criteria reported results of a multivariate analysis to evaluate LVI as an independent prognostic factor of biochemical recurrence. • Eleven (58%) of these studies concluded that LVI was an independent prognostic factor. • Significant heterogeneity in the study population, disease characteristics and quality of the studies prevented meta-analysis of the results. • In the nine studies in which the magnitude of independent association of LVI with recurrence was reported, it ranged from an odds ratio or relative risk of 1.37 to 4.39. CONCLUSIONS • The existing literature is conflicting and of insufficient homogeneity to definitively establish LVI as an important independent prognostic factor of biochemical recurrence in prostate cancer prostatectomy specimens. • Additional adequately powered studies are required to determine the clinical value of reports of LVI involvement. • In the meantime, the use of LVI status as an independent prognostic factor for clinical prognostication and medical decision making is not recommended.

What's known on the subject? and What does the study add? It is well known that the transition of a presented abstract in a scientific meeting to a journal article improves the quality of the meeting and prevents an abstract being incorporated into meta-analyses or practice guidelines without proper appraisal. This is the first analysis of USANZ Annual Scientific Meeting abstracts’ conversion to full publication. With relatively low publication rates compared to other international meetings, this review identifies the need for mechanisms to encourage USANZ researchers to convert their abstracts into published articles. The numbers and characteristics of the abstracts presented at the Annual Scientific Meetings (ASM) of the Urological Society of Australia and New Zealand (USANZ) that are converted to peer-reviewed publications have not previously been analysed and published. We undertook a review of all abstracts presented at the USANZ ASM from 2005 to 2009. A PubMed search was performed between 15 June and 15 July 2012, using a search algorithm to identify the full-text publications of the presented abstracts. Correlation between abstract characteristics and publication rate was then examined to distinguish the predictors for publications. Of 614 abstracts that were presented at USANZ ASM between 2005 and 2009, 183 papers were published, giving a publication rate of 29.80%. The papers were predominantly published in urological journals and were more likely to be published if they were presented by an international author or were retrospective studies or if basic science research. The mean (SD) time to publication was 14.46 (13.89) months and the mean Impact Factor of journals where papers were published was 2.90. The overall publication rate was relatively low compared with other urological meetings held in America and Europe. USANZ has a challenge of encouraging higher-quality research from the authors to further enhance its publication rate and consequently the calibre of the meeting itself.

What's known on the subject? and What does the study add? The conventional 'blind' technique for suprapubic catheter (SPC) insertion relies on adequate filling of the bladder to displace bowel away from the site of needle puncture. However, in a small percentage of patients this fails to happen, which can occasionally lead to life-threatening bowel injury. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. This paper describes the technique of US-guided needle puncture and SPC insertion to reduce the likelihood of bowel injury. The paper addresses training, equipment and logistical issues associated with this advice. We have reviewed the available publications on the outcomes from this technique and also present our experience. Suprapubic catheter (SPC) insertion is a common method of bladder drainage in contemporary urological practice. The procedure involves insertion of a sharp trocar into the bladder percutaneously, usually by palpation, percussion or cystoscopy for guidance. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.4% with a mortality rate of 1.8%. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. The present paper describes the use of US for SPC insertion and discusses the implications of this advice. This paper is designed to support and supplement practical techniques learnt on a course and in clinical practice.

What's known on the subject? and What does the study add? The medical management of urolithiasis is complex. There are many papers written on the topic and many conflicting views. It can be difficult for physicians to interpret these data and have a stepwise approach to the medical treatment of stones. Thus this study provides a framework and a review of the literature to allow physicians to practise evidence-based medicine when medically managing urolithiasis. SUMMARY This review paper provides a summary of medical therapies available for urolithiasis. The summary includes general medical advice, prophylactic medications, dissolution therapy and medical expulsion therapy. The paper is designed to provide a management strategy for all physicians who treat urolithiasis, from general practitioners, to emergency physicians, to urologists. OBJECTIVE • To provide an up to date review of the literature in relation to the medical management of stone disease. This will encompass prophylaxis, dissolution therapy and medical expulsion therapy. PATIENTS AND METHODS • First-time stone formers do not regularly have a full urine and electrolyte evaluation due to the low incidence of a reversible metabolic cause. • However, stone disease is common and over a lifetime urolithiasis can affect up to 10–15% of the population. RESULTS • Medical management of stone disease encompasses preventative measures, medical dissolution and medical expulsion therapy. CONCLUSIONS • Recurrent stone formers should have dietary optimization to decrease the risk of further stones. • Furthermore, the correct use of prophylactic and therapeutic medications can decrease the morbidity associated with ureteric calculi.

What's known on the subject? and What does the study add? This article provides a current update on the risk factors, clinical features, and diagnosis on obstruction after female stress incontinence surgery using the mid-urethral synthetic sling. Particular attention has been paid to identify the patient at risk for developing voiding difficulty post-sling surgery, as well as the utility of urodynamics and various imaging modalities, especially translabial ultrasound, in the diagnostic process. Urethral obstruction is not an uncommon complication after sling surgery for female stress urinary incontinence (SUI). This paper focuses on this complication in the context of the mid-urethral synthetic sling, which is now the predominate surgical option used by many surgeons in the treatment of female SUI. The epidemiology and risk factors predisposing to sling obstruction is reviewed, followed by a description of clinical features used in supporting the diagnosis. The use of urodynamics in conjunction with translabial ultrasound as a novel approach to assess the position of the sling and its relation to the urethra is explained. This is particularly important in the understanding of why the sling obstructs from an anatomical standpoint. The paper concludes with a brief overview on treatment options.

What's known on the subject? and What does the study add? The clinical presentation and complications of lichen sclerosus are well known. What is less well known is the true incidence of the condition. The published figures are all based on attendance at general medical clinics or specialist clinics, but it is likely that the true incidence is much higher than this reported incidence as many men will not present to the doctor for treatment. The other uncertainty is the relationship of lichen sclerosus to the subsequent development of cancer of the penis. As pointed out in the paper, it is likely that between 4% and 8% of men with this condition will develop squamous cell cancer of the penis. However, it is unclear if lichen sclerosus itself causes the development of squamous cell cancer or if it is due to coexistent infection with human papillomavirus. This review provides a concise summary of the clinical and pathological features of the disease and describes its current medical and surgical treatment. It brings together a number of papers which have addressed the association of lichen sclerosus with squamous cell carcinoma of the penis and shows that the likely incidence of carcinoma is approximately 4–8% in men with this condition. SUMMARY Penile lichen sclerosus, also known as balanitis xerotica obliterans, is a chronic inflammatory condition of the penis which can occur at all ages. The inflammation leads to the formation of white plaques most commonly on the foreskin or penis, and can lead to inability to retract the foreskin or blockage to the flow of urine. Cancer may occur rarely. Penile lichen sclerosus is a progressive, sclerosing, inflammatory dermatosis of the glans penis and foreskin which is of uncertain aetiology. Recent studies have shown a link between lichen sclerosus and squamous cell carcinoma of the penis. In this review, we discuss the clinical presentation, pathology and current approach to treatment of this condition.

What's known on the subject? and What does the study add? Prognostic tools, such as the Cancer of the Prostate Risk Assessment (CAPRA) score and the 1998 Kattan and 2006 Stephenson nomograms, predicting biochemical recurrence after radical prostatectomy are widely used for treatment decision making and counselling patients. However, tools derived in certain cohorts tend to perform less well when they are applied to populations that are dissimilar in terms of population or disease characteristics, health systems or treatment practices. Some of the loss in accuracy of a prognostic tool is a consequence of unknown factors and hence the performance of a tool when applied to a different population is unknown and largely unpredictable. This study validates these widely used tools in South Australian patients treated at three public hospitals. All three tools discriminated well according to risk of recurrence in these patients. However, when compared against observed rates of recurrence, it was found that predictions of recurrence varied widely between the three tools, suggesting that their use in counselling patients on such risk may not be appropriate. Interestingly, the oldest of the three tools (Kattan 1998) was the best predictor of absolute risk of recurrence. In the paper, this is linked to later adoption of updated Gleason grading, among other factors. SUMMARY In many countries, prognostic tools, which draw on the experience of thousands of patients with cancer, are used to predict cancer outcomes, but accuracy varies. This paper compares the accuracy of three widely used tools predicting prostate cancer recurrence after surgery in Australian patients. The results show that all tools were good at predicting which patients were most likely to experience recurrence and which were least. However, prediction of absolute risk varied and the oldest tool was the most accurate. OBJECTIVE • To compare performance of the CAPRA score and two commonly used risk assessment nomograms, the 1998 Kattan and the 2006 Stephenson, in an untested Australian cohort. PATIENTS AND METHODS • We present data on 635 men from the South Australian Prostate Cancer Clinical Outcomes Database who underwent radical prostatectomy between January 1996 and May 2009 and had all required variables for predicting biochemical recurrence (BCR). • BCR was defined as prostate-specific antigen ≥0.2 ng/mL or secondary treatment for a rising prostate-specific antigen. • Accuracy was evaluated using Harrell's concordance index, plotting calibration curves, and constructing decision analysis curves. RESULTS • Concordance indices were high for all three tools: 0.791, 0.787 and 0.744 for the 2006 Stephenson nomogram, CAPRA score and 1998 Kattan nomogram respectively. • At 3 years, calibration of the tools (agreement between predicted and observed BCR-free probability) was close to ideal for the 1998 Kattan nomogram, whereas the 2006 Stephenson model underestimated and the CAPRA model overestimated BCR-free probability. • The 1998 Kattan and 2005 CAPRA tools performed better than the 2006 Stephenson nomogram across a wide range of threshold probabilities using decision curve analysis. CONCLUSION • All three tools discriminate between patients' risk effectively. • Absolute estimates of risk are likely to vary widely between tools, however, suggesting that models should be validated and, if necessary, recalibrated in the population to which they will be applied. • Recent development does not mean a nomogram is more accurate for use in a particular population.

What's known on the subject? and What does the study add? Minimally invasive approaches to radical prostatectomy have been touted to lead to superior surgical and functional outcomes with less potential complications despite scant and often conflicting reports in the peer reviewed literature. This review provides evidence that the minimally invasive prostatectomy literature still fails to meet the standards and critical benchmarks necessary for adequate complications reporting. Given our current release on observational studies. Increased effects should be made to standardize all complications and functional outcomes reporting for minimally invasive prostate cancer surgery. To query the minimally invasive urological literature from 2006 to the middle of 2010, focusing on complications and functional outcome reporting in laparoscopic radical prostatectomy (LRP) and robot-assisted LRP (RALP), to see if there has been an improvement in the overall reporting of complications. We performed a Medline search using the Medical Subject Heading terms ‘prostatectomy’, ‘laparoscopy’, ‘robotics’, and ‘minimally invasive’. We then applied the Martin criteria for complications reporting to the selected articles. We identified 51 studies for a total of 32 680 patients. When excluding functional outcomes the outpatient complications reporting was 20/51 (39.2%). In all, 35% and 43% of papers did not list any method for recording continence and potency, respectively. A complication grading system was only used in 30 studies (58.8%). Of the 16 papers using a grading scale in 2006–2007, only 31.3% used the Clavien system, compared with 69% from 2008 to the first half of 2010. In all, 27% of papers used some form of risk-factor analysis for complications. Multivariate analysis was used in 43% of papers, 29% looked at body mass index, while one looked at prostate weight, and another age. There has been an overall improvement in complications reporting in the minimally invasive RP literature since 2005. However, most studies still do not fulfil many of the criteria necessary for standardised complication reporting. Functional outcome reporting remains poor and unstandardised. Given our current reliance on observational studies, increased efforts should be made to standardise all complication outcomes reporting.

What's known on the subject? and What does the study add? Robotic-assisted laparoscopy is currently utilized in the treatment of urogynecological disorders. Multiple papers are available detailing the technique and outcomes of robotic-assisted laparoscopic sacrocolpopexy. Recently robotic-assisted laparoscopy has been used to treat pelvic fistulas. This paper is an overview of the currently published literature pertaining to robotic-assisted laparoscopy in the treatment of urogynecologic disorders. • Urogynaecology is a subspecialty practiced by both urologists and gynaecologists specialised in treating women with pelvic floor disorders and urinary incontinence. • While urogynaecology covers a vast range of disorders, two disorders frequently managed by urogynaecologists are pelvic organ prolapse (POP) and pelvic fistulae. • Surgical intervention is often the treatment option for both POP and pelvic fistulae after all conservative options have been attempted. The daVinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) has applications for the minimally invasive surgical management of POP and pelvic fistulas. • The following review will address the development and current state of robotic assistance in treating these disorders.

What’s known on the subject? and What does the study add? Classically, sensation is the first stage in the functioning of the senses while perception would correspond to interpretation of sensations. This paper explains and argues that sensation and perception are actually two distinct and parallel internal mental stimuli, which are competitive with the two distinct and parallel internal erogenous stimuli: libido and sexual arousal. Both mental and sexual functions use the same somatic peripheral afferents and also perhaps a common autonomic hypothalomic processor. The dual theory of sexuality is a work in progress that tries to put together all the significant physiological aspects described on this subject, the most recent published article discussing about the hormonal and pheromonal neuromodulation of somatic peripheral afferents. But sexuality and cognition shares common somatic peripheral afferents, so that a good understanding of sexual mechanisms supposes also a good knowledge of the essential psychological mechanisms/neuromodulators. Current psychological approaches could be limited to two general tendencies. Some authors consider that cerebral neuronal connexions generate a unitary network substrate that – increasing in its complexity – becomes compatible with our complex mental function. Others suggest that such a complex cerebral function correspond actually to a system based on subsystems, represented by distinct neuronal units (not necessarily complexes) that interact each other. Starting from basic somatic/sexual neurophysiological elements and general accepted psychological aspects, the discussion gave sense to the last point of view, namely that genesis of a new function is the result of cooperation between distinct structural and functional units. Contrary to the classical concepts, this paper sows the fact that mental perception corresponds actually (in term of touch/tangibility) to the internal representation of an external object while sensations realize an internal representation of the external characteristics of environmental object. As a conclusion, sexuality and cognition are two distinct autonomic/dual functions, interrelated at both cerebral and peripheral level. Peripheral interference implies intervention of some specific (mental and sexual) neuromodulators, making external information act as internal mental or internal sexual stimuli. Central cerebral interferences are also clinically and pharmacologically documented, specific neuromodulators being taken into account. Supplementary studies would be necessary to complete psychosexual dualism, presenting the association between image and perception for the genesis of visual perception or between image and sensation for the genesis of visual sensations, complex (mental or sexual) stimuli that suppose a synergic action between distinct neuromodulators. This central synergism supposes a peripheral synergism between left visual field and right nostril, aspects that will be discussed largely in a future article.

What’s known on the subject? and What does the study add? Earlier, role of caspases in cancer initiation and progression was documented. However, our paper is the first to find association of caspase gene polymorphism in PCa progression (CASP 8 -652) and metastasis (CASP 9-1263 G). Moreover, our paper shows that the gene polymorphisms in the promoter region of the gene can play a major role in development of hormone refectory prostate cancer (CASP 8-652). Results from this pilot study may be revaluated, and may be applicable in clinical practice. The PCa subjects with presence of CASP 8 -652 (-/-) allele may not be good subjects for hormone therapy, therefore these patients can be given any other alternative therapy. OBJECTIVE • To investigate, by genotyping CASP8 (−652 6N del/ins) and CASP9 (−1263 A > G; −293 19N del/ins), whether inactivation of apoptosis by genetic polymorphism of caspases 8 and 9 play an integral role in the mechanism of cancer development. • To investigate the role of these polymorphisms in susceptibility to early development of hormone refractory prostate cancer. PATIENTS AND METHODS • The study included 175 histologically confirmed cases of prostate cancer and 198 age and ethnicity matched healthy controls. • CASP9−1263 A > G polymorphism was genotyped using the polymerase chain reaction–restriction fragment length polymorphism method. • CASP9−293 del/ins and CASP8−652 del/ins polymorphisms were genotyped and the deletion pattern analysed by polyacrylamide gel electrophoresis. RESULTS • Our results demonstrated that presence of CASP9−1263 G allele was associated with reduced risk for prostate cancer (odds ratio 0.6, 95%CI 0.39–0.92, P= 0.02). Other variant CASP9 was not associated with prostate cancer risk. • Coincidentally, the presence of CASP9−1263 G allele was associated with increased risk for progression of prostate cancer to bone metastasis (odds ratio −2.28, 95%CI 1.14–4.53, P= 0.02). • CASP8–652 (+/−) genotype was associated with increased hazard for early development of hormone refractory prostate cancer (hazard ratio 2.44, 95%CI 1.2–5.85, P= 0.045). CONCLUSION • Our results support the hypothesis that variants of CASP9 may influence the susceptibility to prostate cancer and its progression to bone metastasis. • CASP8 polymorphism may influence the progression of prostate cancer disease to a hormone refractory state.

The first three papers in this section relate to the use of radical cystectomy in bladder cancer, and each study describes issues which are uncommonly written about, but which are relevant and important to any urologist who manages such patients. There is also a paper from Cleveland describing the rare condition of neuroendocrine tumours in the kidney. This is a large series of cases, and the authors recommend awareness of the condition and the prudent use of immunohistochemical neuroendocrine markers. There are a further six papers on prostate cancer; two of them evaluate high-grade prostatic intraepithelial neoplasia, taking different views on the subject. OBJECTIVE To examine the association between the interval from the last transurethral resection (TUR) to radical cystectomy (RC) and bladder cancer-specific outcome, as the decision to proceed to RC for an individual patient is complex, and recent reports suggest an interval from diagnosis to RC of >3 months is associated with adverse outcomes. PATIENTS AND METHODS The records of 592 patients who had RC were reviewed; the interval from the last TUR was analysed as both a continuous and categorical variable (

In this section this month, we have two papers. The first is from authors from Scotland. They present a review of patients with an extended follow-up who have undergone extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones over a 15-year period to assess long-term outcome, irrespective of treatment. They concluded that PCNL is an effective and durable means of treating calyceal diverticular stones, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients are rendered symptom-free with minimal complications. The second paper is from the USA; the authors discuss the new generation of flexible ureteroscopes, which provide exaggerated active deflection to facilitate intrarenal manipulation. They compared the relative ease of manipulation around a calyceal model. The authors concluded that the Wolf Viper proved superior for manipulation in the hands of experienced endoscopists. OBJECTIVE To review patients with an extended follow-up after extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones (CDS), over a 15-year period, assessing the long-term outcome. PATIENTS AND METHODS In all, 56 patients were treated for symptomatic CDS disease by ESWL (38) or PCNL (18). The stone-bearing diverticula were in the upper calyces in 26, middle calyces in 24 and lower calyces in six patients, and in the right kidney in 22 and in the left in 34. The most frequent symptom was ipsilateral flank pain (84%) and 32% of patients presented with associated chronic urinary tract infections. In a retrospective analysis, we assessed stone size, diverticulum location, stone-free rate, symptom-free rate, complications and extended follow-up. RESULTS In the short-term in the ESWL group, 21% of patients were stone-free and 61% were asymptomatic; 8% developed symptoms and 8% developed recurrence or stone-growth in the long term. There were six minor complications. In the PCNL group, 15 patients (83%) were stone-free in the short term; two had a recurrence (11%) and two had stone growth (11) in the long term. There were three complications after PCNL. CONCLUSIONS This series shows that PCNL is an effective and durable means of treating CDS, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients were rendered symptom-free with minimal complications. The long-term recurrence rates, 8% for ESWL and 11% for PCNL, were comparable.

The urological oncology section is relatively long this month, and this reflects the many high-quality manuscripts we receive. When you consider our relatively high rejection rate, you will understand just how many papers on this topic are submitted. The high quality of oncology papers is clear in this month’s section. You will also notice that all but one of them are on prostate cancer, and the reason for this is similar to that mentioned above, as this topic is, as might be expected, the most commonly submitted in this section. However, I am only too happy to reassure readers, and those primarily interested in other types of urological cancer, that the imbalance in this month’s section is not a permanent fixture. OBJECTIVE To determine the feasibility of using flow cytometry fluorescence-activated cell sorting (FACS) analysis for detecting circulating epithelial cells (CECs) in patients with hormone-refractory prostate cancer (HRPC), and to determine whether CECs can be used to predict survival in these patients. PATIENTS AND METHODS Several prognostic models that include routinely used clinical and laboratory variables for predicting survival in men with HRPC have been reported; the presence of CECs measured by reverse transcriptase-polymerase chain reaction for prostate-specific antigen (PSA) in patients with HRPC is an independent prognostic factor for survival. CECs detected by FACS analysis correlate with advanced stage and poor survival outcome. A retrospective study was conducted to assess the presence of CECs by FACS analysis in metastatic HRPC patients initiating systemic chemotherapy with a taxane-based regimen. The association between clinical variables previously described and the presence of CECs along with the effect of the magnitude of CECs on survival was calculated, in 41 patients with HRPC, all of whom had peripheral blood collected for FACS analysis. RESULTS Except for four patients, all those with metastatic HRPC had detectable CECs. Among these patients, the number of CECs/mL was correlated with age, serum PSA level and serum alkaline phosphatase (ALP). Higher serum levels of PSA and ALP predicted a poor survival outcome. Similarly, patients with ≤1.8 CECs/mL had a significantly longer survival than those with more CECs/mL (P = 0.02). With a median follow-up of 15.4 months, the median overall survival for all patients was 18.4 months. CONCLUSIONS The presence of more CECs in patients with metastatic HRPC was associated with a poorer survival outcome; levels of ≥1.8 CECs/mL were associated with a shorter survival in patients with metastatic HRPC.

Many of the papers in this section are specifically related to the complexities of PSA testing and prostatic biopsy. Increasingly PSA testing has become a constituent part of urological practice, and although most would maintain that its is the best urological marker for prostate cancer that we have, its failings have led us to examine its performance in microscopic detail, to help us to use it better for detecting prostatic cancer. In the same way, high-grade prostatic intraepithelial neoplasia has become important in our understanding of the progression of the pathology of prostate cancer. Several papers in this section re-emphasise the importance of this finding, and suggest that it remains a highly significant indicator of the likely development of prostate cancer.

The role played by Andrew Novick and his team in the Cleveland Clinic in the development of nephron-sparing surgery for RCC has been obvious to all who are involved in the speciality of urological oncology. Interestingly, the laparoscopic revolution is also concentrating its efforts in this area also, through Inderbir Gill and others. In this section, the Cleveland Clinic team describe a technique which will help with the fine-tuning of this method of treating renal cancer. Also in this section is a study from Boston by Michael Barry and his co-workers on the rising prevalence of androgen deprivation among men in the PSA era. There are also other papers on prostate cancer, particularly what I think will be one of a series of great interest from Northern Ireland on PSA testing. The other papers in this section will also be of great interest. OBJECTIVES To assess the ability of helical computed tomography (CT) including multiplanar reformatting and volume rendering (3D CT) to predict collecting system entry at surgery, as helical CT can be used to delineate renal tumour and normal renal anatomy before nephron-sparing surgery (NSS). PATIENTS AND METHODS Knowledge of the possibility of collecting system entry during surgery might either dissuade some surgeons from NSS in elective situations or influence the operative approach or ablative technology in cases where NSS is imperative, or prepare the surgeon for the possibility of collecting system repair. We reviewed all 3D CT (349 scans) obtained before NSS at our institution over three consecutive years. Tumour size, central tumour extension, and presence of calyceal involvement were prospectively recorded at the time of 3D rendering. Collecting system entry was analysed for these three CT variables, and for three clinical variables (tumour side, size and surgical approach) collected retrospectively from the medical records. Multivariate logistic regression was used to assess the sensitivity, specificity, and positive and negative predictive values. RESULTS Of 344 patients, 170 had collecting system entry reported at surgery. There were statistically significant associations between collecting system entry and central tumour location by CT (sensitivity 58.8%, specificity 80.5%, P 4 cm (sensitivity 39.4%, specificity 74.7%, P = 0.005). There were no significant associations with side or type of surgery (P > 0.83). CONCLUSION Helical CT is a reliable predictor of calyceal entry at surgery.

This section contains papers from Japan, Austria, the UK, and joint papers from France, Denmark, Switzerland, Australia and the USA. A wide variety of lower urinary tract topics is covered, from BPH to overactive bladder and urodynamic stress incontinence. OBJECTIVE To verify the efficacy and safety of the new α1A-adrenoceptor-selective antagonist silodosin compared with tamsulosin and placebo in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). PATIENTS AND METHODS This randomized, double-blind, placebo-controlled study was conducted at 88 centres in Japan. Men aged ≥50 years with an International Prostate Symptom Score (IPSS) of ≥8, a quality-of-life (QoL) score of ≥3, a maximum urinary flow rate (Qmax) of

There is a wide variety of topics in this section of the Journal this month. The papers come from Austria, Israel, Scotland, Denmark, England and Australia. I am, as ever, pleased that the Journal continues to receive papers from so many countries, and that the high standard of these papers help us to maintain a quality product of great general interest to the reader. OBJECTIVE To evaluate prostatic vascular resistance by measuring the resistive index (RI), and flow velocity using colour Doppler ultrasonography (CDUS), in normal prostates and in patients with benign prostatic hyperplasia (BPH) or prostate cancer, as BPH is considered to be a result of urogenital ageing and studies suggest that hyperplasia in the stromal and glandular compartments might be induced by stromal growth secondary to hypoxia, which in turn results from abnormal blood flow patterns. PATIENTS, SUBJECTS AND METHODS Ninety-two men (22 with normal prostates, 45 with BPH and 25 with prostate cancer; mean age 56 years) were prospectively evaluated by CDUS. The RI values for the peripheral, central and transition zones were assessed by one investigator. The diagnosis of BPH and prostate cancer was established from histological findings. RESULTS The mean (sd) RI in the transition zone was significantly higher only in patients with BPH, at 0.77 (0.05), vs 0.65 (0.05) in the other two groups. In the peripheral and central zones there was no significant difference in the RI among the three groups. Arterial CDUS flow velocity was increased in the transition zone of patients with BPH, but not in the peripheral and central zones. CONCLUSIONS The present results support the hypothesis that an age-related impairment of blood supply to the lower urinary tract might have a role in the development of BPH. Although prostate cancer cannot be excluded by measuring RI, high RI values (>0.75) in the transition zone are indicative of BPH.

The first mini-review is a critique of some of the methods used to assess endpoints for drug studies in oncology. The authors review studies using tumour shrinkage and those assessing time to progression. The next paper is a Pubmed-based overview of published reports to establish whether antimuscarinic drugs exert their therapeutic action on detrusor overactivity by reducing the ability of the detrusor to contract. The findings are interesting and somewhat unexpected. Authors from several centres in Europe review anaesthesiology considerations and requirements for endoscopic extraperitoneal and laparoscopic transperitoneal radical prostatectomy. Finally, a touch of history; we do not have a history section, but occasionally we accept papers dealing with pioneers in urology. Recently we had an Irish pioneer, so it is highly appropriate to include one on a Scottish urological leader, Dr Henry Wade. In oncology there have been many new putative anticancer drugs based on the improving understanding of oncogenesis and the malignant phenotype. On the basis of their mechanism of action and preclinical data, many of these drugs are expected to inhibit growth. As such, dramatic tumour shrinkage, which has been the classic endpoint for phase II drug studies, might not be a valid or useful measure by which to make decisions as to whether further phase III trials are indicated. Because this is a critical decision point in the overall drug development plan, alternative endpoints and designs need to be considered. More traditional single-arm phase II designs using tumour shrinkage endpoints are reviewed, and the use of randomized phase II designs assessing time to progression discussed. It is postulated that randomized approaches will decrease the current high failure rate for oncological drugs in phase III trials.

In this section there is a wide diversity of mini-reviews, covering several areas of interest for readers. Authors from the USA write about clinical trials in patients with biochemically relapsed prostate cancer, again bridging the divide between medical oncologists and urologists who specialise in urological oncological surgery. The second paper is a joint one from Germany and the USA, bringing the reader up to date with advances in the treatment of stress urinary incontinence. Finally there are two papers from Australia describing the use of positron emission tomography in renal cancer and in prostate cancer.

Objective To systematically review the literature regarding clinical outcomes of 180-W XPS GreenLight laser (GL) vaporisation for the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH). Methods Recent publications were identified in the field of 180-W GL vaporisation for the treatment of LUTS due to BPH. We searched for peer-reviewed original articles in the English language. Search items were: '180W lithium triborate laser' or '180W greenlight laser' or '180 watt lithium triborate laser' or '180 watt greenlight laser' or 'XPS greenlight laser'. In all, 30 papers published between 2012 and 2014 matched this search. Of these, 10 papers were identified dealing with consecutive cohorts of patients treated with the 180-W XPS GL RESULTS: The 10 papers included a total experience of 1640 patients. The only randomised controlled trial in this field compares 180-W with transurethral resection of the prostate (TURP). Functional outcomes and prostate volume reduction after GL vaporisation were similar to TURP. Catheterisation time and hospital stay were shorter in patients undergoing 180W XPS GL vaporisation (41 and 66 h vs 60 and 97 h, respectively). Four papers compared the 180-W XPS system to former GL devices showing increased operation time efficiency and comparable postoperative voiding results and adverse events. One paper defined the learning curve to achieve an expert level according to the speed of the procedure and the effectiveness of volume reduction was met after 120 procedures. Conclusion The 180-W XPS GL offers shorter operation times than former devices. In the one randomised controlled trial comparison with TURP, volume reduction and functional results were comparable to those of TURP. Longer term studies are required.

Authors from the National Cancer Institute present a study which assessed the time to androgen independence and overall survival for patients with metastatic prostate cancer. They reported a longer than expected survival with androgen-independent prostate cancer, and make original observations on the time to metastatic disease for patients with no evidence of radiographic disease. The new wave of chemotherapeutic agents for hormone-resistant prostate cancer has generated a new interest in producing more. Dr Cora Sternberg from Rome presents information on satraplatin, a third-generation orally available platinum analogue that shares more structural similarities with cisplatin. There are several other papers in this section on prostate bladder and renal cancer, and finally a paper from London on penile cancer, asking what surgical resection margins are required to achieve oncological control, and finding that the traditional 2 cm margin may be unnecessary, with excision margins of only a few millimetres needed to give excellent control. OBJECTIVE To determine the natural history of patients with prostate cancer who start initial androgen-deprivation therapy (ADT) for biochemical failure with no radiographic evidence of disease (D0) or with radiographic metastatic disease (D2), as the history is either not well-defined or is changing, and such data are critical for guiding therapy after prostate cancer recurrence. PATIENTS AND METHODS We retrospectively assessed the time to androgen-independence (AI), defined as the first sustained rise in prostate-specific antigen (PSA) level on ADT, time to metastatic disease and overall survival for 80 patients with metastatic prostate cancer in clinical trials at the National Cancer Institute. RESULTS ADT was initiated after metastatic disease in 37 patients and before metastatic disease in 43 patients; in these 43 patients, the median time to developing metastatic disease on ADT was 37.8 months. The median time to AI from the initiation of ADT was 19.3 and 13.1 months in D0 and D2 patients, respectively. The median overall survival from the start of ADT was 89.0 and 63.0 months, and the median overall survival from the time of AI was 63.1 and 44.2 months in D0 and D2 patients, respectively. These 80 patients, which included 43 who had no metastatic disease when starting ADT, had a median survival of 54.8 months after AI prostate cancer. CONCLUSIONS We describe the natural history of AI prostate cancer in D0 patients who eventually developed metastasis, and in D2 patients. The results suggest a longer than expected survival with AI prostate cancer, and to our knowledge this is the first study to report the time to metastatic disease for D0 patients from ADT and from AI. These results can be used to help design clinical trials in patients with D0 prostate cancer.

In the first paper in this section, authors from the Mayo Clinic describe their experience and 15-year outcomes in the controversial subject of radical prostatectomy in patients with clinical T3 prostate cancer. The findings were interesting in many respects, but the authors concluded that radical prostatectomy as part of multimodal treatment for patients with clinical T3 disease offers cancer control and good survival rates. There follows a series of papers on both prostate cancer and bladder cancer, but the final paper in this section from the UK attempts to define the accuracy of urologists and oncologists in assessing patient life-expectancy. Using various methods they found that, rather disappointingly, doctors were poor at predicting 10-year survival, leading to the possible outcome that some patients may be denied treatment after a pessimistic assessment of life-expectancy. OBJECTIVE To report a long-term experience with extirpative surgery in patients presenting with locally advanced (cT3) prostate cancer, as the best management of such patients remains a problem. PATIENTS AND METHODS In a single-institution retrospective study identifying 5652 men who had radical prostatectomy (RP) for histologically confirmed prostate cancer since the advent of prostate-specific antigen (PSA) testing (1987–97), 15% (842) had RP for cT3 disease. The median follow-up of these men was 10.3 years. Cancer-specific, overall and disease-free survival was plotted and compared with those of patients having RP for cT2 disease during the same period. Perioperative morbidity, continence and erectile function rates were examined, with a multivariate analysis for risk factors of disease recurrence. RESULTS Freedom from local or systemic disease at 5, 10, and 15 years after RP for cT3 disease was 85%, 73% and 67%; the respective cancer-specific survival rates were 95%, 90% and 79%. Significantly many men who did not receive neoadjuvant therapy (27%) were clinically over-staged (pT2) and most men with pT3 disease (78%) received adjuvant therapy. The mean time to adjuvant therapy after RP was not significantly different between men with cT3 and cT2 disease (4.0 and 4.3 years). Pathological grade (≥7), positive surgical margins, and nondiploid chromatin were all independently associated with a significant risk for clinical disease recurrence, while preoperative PSA level had little effect on outcome. Complications and continence rates after RP in patients with cT3 mirrored those in patients with cT2 disease. CONCLUSIONS Significantly many patients with cT3 prostate cancer are overstaged (pT2) in the PSA era. RP as part of a multimodal treatment strategy for patients with cT3 disease offers cancer control and survival rates approaching those achieved for cT2 disease. Pathological grade, ploidy and margin status are all significant predictors of outcome after RP. Complications and incontinence rates in patients with cT3 disease mirror those after RP for cT2 disease.

In a study of patients with BOO and an overactive bladder, authors from Seoul and Pittsburgh compared the use of doxazosin with or without tolterodine. The combination of the two drugs was helpful in most patients, but doxazosin alone was also effective. The impact of controlled-release delivery of drugs on patient comfort has been considerable. The paper by authors from Germany and the USA describes the effect of the leader in this field on the pharmacokinetics of oxybutynin at different dosages. They confirm that this technology facilitates the severity-dependent treatment of the overactive bladder with flexible-dose adaptations to patient requirements. There are two papers on virtual cystoscopy, in one case using CT and in the other IVU. The authors report that virtual cystoscopy is valuable in investigating patients, drawing attention to its benefits and shortcomings. OBJECTIVE To assess the efficacy of combined treatment with doxazosin and tolterodine, as although α-blockers are commonly used and generally effective in men with symptomatic bladder outlet obstruction (BOO), a subset of men with BOO and overactive bladder (OAB) symptoms often complain of persistent symptoms. PATIENTS AND METHODS In a prospective study of 144 consecutive men with BOO at one tertiary urology centre, all had a baseline pressure-flow urodynamic study and were then subdivided into those with BOO or BOO + OAB, based on absence or presence of involuntary detrusor contractions. The Abrams–Griffiths nomogram was used to determine obstructive BOO. After the initial evaluation, all patients were treated with doxazosin 4 mg/day for 3 months. In patients with no symptomatic improvement, tolterodine 2 mg twice daily was added for an additional 3 months. RESULTS Of the 144 patients, 76 (53%) were diagnosed as having BOO and 68 (47%) BOO + OAB. The patients with BOO + OAB were older (P

In many men from the PLCO screening trial authors from the USA identified risk factors for BPH. Their findings are interesting; Asian Americans were at the lowest risk of clinical BPH, with alcohol and possibly cigarettes related to a lower risk for the condition. Three further papers investigate various epidemiological aspects of LUTS. I think that it is important for we urologists to have a sound epidemiological knowledge of this subject, to answer the increasingly educated questions of our patients. A further paper from Barcelona describes the results of a urodynamic study in patients with bladder calculi. The authors found that bladder stones are not necessarily associated with BOO, and that the results of urodynamic testing are not influenced by their presence. OBJECTIVE To identify risk factors for benign prostatic hyperplasia (BPH). SUBJECTS AND METHODS Medical history data, including reported urological conditions and treatments, and risk factor data were collected from 34 694 participants in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized controlled trial designed to evaluate methods for the early detection of cancer. RESULTS Asian men had the lowest risks (odds ratio, 95% confidence interval) for nocturia (0.7, 0.5–0.9), physician-diagnosed BPH (0.3, 0.2–0.5) and transurethral prostatectomy (TURP, 0.2, 0.1–0.6), while risks for Whites and Blacks were similar for most measures of BPH. Greater alcohol intake was associated with decreased nocturia (P trend = 0.002), BPH (P trend < 0.001) and TURP (P trend

Over the past few months Gillespie has published several papers in the BJU International investigating the overactive bladder and BOO, using novel models and theories. This next paper continues these concepts and shows that the mechanisms influencing the frequency of agonist-induced phasic activity in the isolated bladder model is slowed by cAMP. These findings will have important implications in future pharmacological strategies in the overactive bladder. OBJECTIVE To explore the influence of intracellular cAMP on phasic activity in the isolated bladder (phasic rises in intravesical pressure associated with waves of contraction and local stretches that can be activated by muscarinic or nicotinic agonists), as it has been argued that this activity underlies nonmicturition contractions, and that it contributes to the generation and modulation of afferent nerve activity. MATERIALS AND METHODS Isolated whole bladders from female guinea pigs (270–300 g) were cannulated via the urethra and suspended in a chamber containing oxygenated Tyrode solution at 33–35 °C. Bladder pressure was recorded and pharmacological agents added to the solution bathing the abluminal surface of the bladder. RESULTS Forskolin (1–3 µmol/L), an activator of adenyl cyclase, reduced the frequency and amplitude of the phasic activity induced by the muscarinic agonist arecaidine (300 nmol/L). There were similar changes in frequency and amplitude in bladders exposed to the nonspecific phosphodiesterase (PDE) inhibitor iso-butyl-methyl-xanthene (IBMX). The actions of specific PDE inhibitors were explored to assess which isoenzymes might be responsible for regulating phasic activity. ENHA (PDE-2), zaprinast (PDE-5, -6, -8, -9 and -11) and siguazodan (PDE-3) had no effect. Zardavarine (PDE-3, -4) and Ro 20-1724 (PDE-4) reduced both the frequency and amplitude of the phasic activity. Nerve-mediated rises in intravesical pressure were also inhibited by Ro 20-1724, and the inhibition was more pronounced at 6.5 Hz than at 30 Hz stimulation. Ro 20-1724 inhibited nerve-mediated fluctuations induced by prolonged (200 s) stimulation at 6.5 Hz. CONCLUSION The mechanisms influencing the frequency of agonist-induced phasic activity in the isolated bladder are slowed by cAMP. Degradation of intracellular cAMP in the cells responsible for phasic activity appears to involve primarily PDE-4. The importance of these observations in relation to the overall physiological regulation of the bladder are discussed, and the possible importance of these findings in the development of pharmacological strategies to modulated bladder activity reviewed.

In this section there are papers describing studies into nocturnal polyuria, the overactive bladder in Asian men and the use of extracorporeal magnetic stimulation for female urinary incontinence. There are also papers which evaluate the cost implications of microwave thermotherapy, the accumulation of proteoglycans in prostatic hyperplasia, and the presentation and management of urethral calculi. The last two papers in this section have nothing directly to do with the lower urinary tract. Indeed, they do not fit into any of the groups of papers in the journal but I felt that they were of general interest to the readership of the BJU International, and so felt they could really be put into any section! OBJECTIVE To determine the age prevalence of nocturnal polyuria among older women in the community, and to investigate the relationship between nocturnal polyuria and nocturia. PATIENTS AND METHODS In all, 1183 women aged ≥ 50 years, who were registered with a family doctor practice and who had taken part in a prevalence study, were sent brief questionnaires and a frequency/volume chart (FVC) to complete. RESULTS There were 227 FVCs with adequate data and 264 completed questionnaires available for analysis. The prevalence of nocturnal polyuria increased disproportionately with age. There was no clear relationship between nocturia or nocturnal polyuria and daytime frequency, nor was there a clear relationship between diuretic use and nocturnal polyuria. CONCLUSION Nocturnal polyuria is common among women in the community and not obviously related to daytime frequency. Night-time symptoms are common in women as well as men, and are troublesome to them.

What's known on the subject? and What does the study add? There has been little documentation of the contribution Dr Alban Gee made to the development of Urology in Australasia. This paper records a personal association with Dr Gee for the Archives of the Urological Association of Australia and New Zealand which did not previously exist. This paper documents Dr Gee's contribution to Australasian Urology.

In this section there are four papers on a variety of topics. The subject of antitumour natural killer cells is addressed in patients with advanced prostate cancer. In another study, the authors describe their work into the effect of oestrogen and testosterone on the urethral seam of the developing male mouse genital tubercle. Another group of authors studied ion-channel currents of smooth muscle cells isolated from the prostate of the guinea pig, and the final paper describes how a novel pyrrole derivative, NS-8, suppresses the rat micturition reflex by inhibiting afferent pelvic nerve activity. OBJECTIVE To examine whether antitumour natural-killer (NK) cells can be induced from peripheral blood mononuclear cells (PBMCs) of patients with advanced prostate cancer, as cell therapy using antitumour immune cells is a promising candidate treatment but such patients generally have a suppressed immune response against cancer cells. PATIENTS AND METHODS PBMCs were obtained from 10 patients (four with stage D2 and six with stage B or C disease). For the NK cell expansion, PBMCs were co-cultured with irradiated HFWT cells, a cell line originating from Wilms’ tumour, in RHAM α culture medium supplemented with 5% autologous plasma and interleukin-2 (200 U/mL) for 2 weeks. RESULTS When PBMCs were co-cultured with HFWT cells, lymphocytes from all patients had a 20- to 130-fold expansion after 2 weeks of culture. The CD16+ CD56+ cells constituted > 70% of the proliferated lymphocyte population. The induced NK cells had significantly greater cytotoxicity against a prostate cancer cell line (PC-3) than lymphocytes cultured with no HFWT cells. There was no significant difference in growth and phenotypes of lymphocytes and the induced NK cell activity between patients with stage D2, B or C. CONCLUSION NK cells with potent cytotoxic activity against prostate cancer cell lines from patients with advanced prostate cancer were selectively expanded. Further investigation is needed to determine whether this approach could be a candidate for cell therapy for advanced prostate cancer.