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This study by the Scandinavian Prostate Cancer Study Group highlights the importance of the addition of local radiotherapy to hormonal management in the treatment of high risk, non metastatic, prostate cancer. A total of 875 patients from 47 centers in Norway, Sweden, and Denmark were diagnosed histologically with carcinoma prostate and if they were younger than 76 years old, had a good performance status, and a life expectancy of at least 10 years, were included in the study. Metastasis was ruled out with a bone scan and pulmonary roentgenogram. All patients with Prostate Specific Antigen (PSA) > 11 ng/ ml, were subjected to a pelvic lymph node dissection and were included in the study only if the nodal status was negative. They were subsequently randomized using a block randomization system with a block size of 4. All patients received maximum androgen blockade with an LHRH agonist, leuprorelin, and flutamide for 3 months. They continued on flutamide at a dose of 750 mg in three divided doses. This was continued until death or progression. A total of 20% of the patients had to be changed to bicalutamide due to intolerance to flutamide. At 3 months, the combination group received radiotherapy in addition to the endocrine management. The median dose of radiotherapy was 70 Gy. Follow-up was initially every 3 months for the first year and subsequently every 6 months. A thorough clinical examination, haemogram, PSA estimation, liver function tests, and recording of adverse effects constituted the follow-up. The baseline characteristics were evenly matched. A total of 188 of the 875 patients had T2 tumors or smaller. The mean follow-up was 7.6 years. The cumulative incidence of cancer specific mortality was significantly lower in the group receiving both hormonal manipulation and radiotherapy (11.9% as compared with 23.9% in the hormone alone group). This was highly statistically significant. The cumulative incidence of death from other causes was also higher in the endocrine group. What was even more marked were the PSA recurrences at 7 and 10 years. This was 74.7% at 10 years in the endocrine group, as compared with 25.9% in the group with combination therapy (with a relative risk of 0.16 with statistical significance). The quality of life scores were not very different, except for diarrhea, which was more in the group that received radiation. [ABSTRACT FROM AUTHOR]

In this prospective trial, Pennesi et al, randomized 100 children with vesicoureteral reflux (VUR) into a treatment arm, which received two years of oral sulfamethoxazole/ trimethoprim and a control arm that did not receive any chemoprophylaxis. Based on prior trials, a sample size of 48 was required for a 30% absolute risk difference. Analysis was done on an intention to treat basis. Children between the age of 1 day and 30 months at first episode of pyelonephritis were included. As Grade 1 would spontaneously resolve in the majority, and grade five has a high probability of being associated with renal dysplasia, only children who had grades 2-4 VUR were included. Voiding cystourethrography was performed in all, two months following the acute pyelonephritis. Renal ultrasound and DMSA scan were performed at six months. Although antibiotic prophylaxis was discontinued at two years in the intervention group, all subjects were followed up for a total period of four years. The results were quite an eye opener. Contrary to prior understanding, in the chemoprophylaxis group, there was a slightly higher risk, though not statistically significant, for developing pyelonephritis (RR 1.42 in the first year and 1.25 in the second year). 36% children in the prophylaxis group and 30% in the control group had at least one episode of pyelonephritis in the first two years. In the subsequent two years, both groups did not receive any prophylaxis. Only one in the intervention group and two in the control group developed pyelonephritis. However, it is noteworthy that all pyelonephritis episodes in the intervention arm were caused by multiresistant bacteriae, as opposed to sensitive organisms in the control group. There was no difference in the rate of renal scars or resolution of reflux between both groups. The authors conclude that antibiotic prophylaxis is ineffective either to prevent pyelonephritis recurrence, or to alter the course of the primary pathology. [ABSTRACT FROM AUTHOR]

Petterson et al., identified 16,983 Swedish men from the Swedish Hospital Discharge Register who underwent orchidopexy for undescended testis, between 1964 to 1999. As almost all patients in Sweden are treated at public hospitals, this data was fairly comprehensive. Subjects who underwent orchidopexy before the age of 20 years were included. Two hundred and five men who emigrated from Sweden after surgery but did not immigrate back before the start of their follow-up and one who had testicular cancer at the time of beginning the study were excluded. Other exclusion includes those with ambiguity on information on date of orchiodopexy or sex. The subjects were followed from 15 years of age or the age of orchidopexy plus one year, whichever occurred earlier, till the date of diagnosis of testicular cancer, upper age limit of 55 years, emigration, death, or December 2000. The authors have calculated the expected period-specific incidence for five-year age periods, based on the incidence in the Swedish general population. Based on the observed number of cases in the study population, the relative risk was estimated. They used a number of covariate analyses, including separation of the follow-up into three distinct calendar periods, time of orchidopexy and the place where orchidopexy was performed. Further statistical analysis using Schoenfeld residuals indicated that the assumption of hazard ratio was correct, and all such confounders were eliminated. The mean follow-up was 12.4 years. Mean age at orchidopexy was 8.6 years. Though only 20 cases was expected in the study group based on the incidence in the general population, 56 were documented. The standardized incidence ratio of testicular cancer in those undergoing orchidopexy before the age of 13 years was 2.23, as opposed to those above the age of 13 years, where it was almost double at 5.40. [ABSTRACT FROM AUTHOR]

External urinary drainage devices are in wide clinical uses. There are only a few reports of complications from improper use of condom catheters. We present a case of fibroepithelial polyp of the penis, due to long-term usage of condom catheter. The lesion affected the ventral aspect of the penis. He was successfully treated with wide local excision. The histopathological diagnosis was a fibroepithelial polyp. [ABSTRACT FROM AUTHOR]

Introduction: Shared decision making (SDM) is widely encouraged by both the American Urological Association and Choosing Wisely for prostate cancer screening. Implementation of SDM is challenging secondary to time constraints and competing patient priorities. One strategy to mitigate the difficulties in implementing SDM is to utilize a decision aid (DA). Here we evaluate whether a DA improves a patient's prostate cancer knowledge and affects prostate-specific antigen (PSA) screening rates., Materials and Methods: Patients were randomized to usual care (UC), DA, or DA + SDM. Perception of quality of care was measured using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Outcomes were stratified by long term provider relationship (LTPR, > 3 years) versus short term provider relationship (STPR, < 3 years). Knowledge of prostate cancer screening and the decision regarding screening were assessed. Groups were compared using ANOVA and logistic regression models., Results: A total of 329 patients were randomized. Patients in the DA + SDM arm were significantly more likely to report discussing the implication of screening (33% DA + SDM, 22% UC, 16% DA, p = 0.0292) and answered significantly more knowledge questions correctly compared to the UC arm (5.03 versus 4.46, p = 0.046). However, those in the DA arm were significantly less likely to report that they always felt encouraged to discuss all health concerns (72% DA, 78% DA + SDM, 87% UC, p = 0.0285). Interestingly, STPR patients in the DA arm were significantly more likely to undergo PSA-based prostate cancer screening (41%) than the UC arm (8%, p = 0.019). This effect was not observed in the LTPR group., Conclusions: Providing patients a DA without a personal interaction resulted in a greater chance of undergoing PSA-based screening without improving knowledge about screening or understanding of the consequences of this decision. This effect was exacerbated by a shorter term provider relationship. With complex issues such as the decision to pursue PSA-based prostate cancer screening, tools cannot substitute for direct interaction with a trusted provider.

Introduction: Patients with low-risk prostate cancer (PCa) often have excellent oncologic outcomes. However, treatment with curative intent can lead to decrements in health-related quality of life (HRQoL). Patients treated with radical prostatectomy have been shown to suffer declines in urinary and sexual HRQoL as compared to those managed with active surveillance (AS). Similarly, patients treated with external-beam radiation therapy (EBRT) are hypothesized to experience greater declines in bowel HRQoL. As health-related quality-of-life (HRQoL) concerns are paramount when selecting among treatment options for low-risk PCa, this study examined HRQoL outcomes in men undergoing EBRT as compared to AS in a prospective, racially diverse cohort., Methods: A prospective study of HRQoL in patients with PCa enrolled in the Center for Prostate Disease Research (CPDR) Multicenter National Database was initiated in 2007. The current study included patients diagnosed through April 2014. HRQoL was assessed with the Expanded Prostate Cancer Index Composite (EPIC) and the Medical Outcomes Study Short Form (SF-36). Temporal changes in HRQoL were compared for patients with low-risk PCa managed on AS vs. EBRT at baseline, 1-, 2-, and 3 years post-PCa diagnosis. Longitudinal patterns were modeled using linear regression models fitted with generalized estimating equations (GEE), adjusting for baseline HRQoL, demographic, and clinical patient characteristics., Results: Of the 499 eligible patients with low-risk PCa, 103 (21%) selected AS and 60 (12%) were treated with EBRT. Demographic characteristics of the treatment groups were similar, though a greater proportion of patients in the EBRT group were African American (P = 0.0003). At baseline, both treatment groups reported comparable HRQoL. EBRT patients experienced significantly worse bowel function and bother at 1 year (adjusted mean score: 87 vs. 95, P = 0.001 and 89 vs. 95, P = 0.008, respectively) and 2 years (87 vs. 93, P = 0.007 and 87 vs. 96, P = 0.002, respectively) compared to patients managed on AS. In contrast to those on AS, more than half the number of patients who received EBRT experienced a decline in bowel function (52% vs. 17%, p=0.003) and bother (52% vs. 15%, P = 0.002) from baseline to 1 year. Patients who received EBRT were significantly more likely to experience a decrease in more than one functional domain (urinary, sexual, bowel, or hormonal) at 1 year when compared with those on AS (60% vs. 28%, P = 0.004)., Conclusions: Patients receiving EBRT for low-risk prostate cancer suffer declines in bowel HRQoL. These declines are not experienced by patients on AS, suggesting that management of low-risk prostate cancer with AS may offer a means for preserving HRQoL following prostate cancer diagnosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Intracavernosal injection therapy with vasoactive agents for treatment of erectile dysfunction has been around for more than 3 decades since its advent in the early 1980s. Common complications include ecchymosis and hematoma at the site of injection, priapism, and fibrosis. We describe a rare but potentially dangerous complication of breakage of needle during administering of injections, and discuss its successful retrieval., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Sex cord stromal tumors of the testis comprise less than 5% of testicular neoplasms. Consequently, data regarding patterns of care and survival are sparse. Using a large national database, we sought to provide a more definitive analysis of outcomes and management of these malignancies., Materials and Methods: Data were obtained from the National Cancer Data Base. Patients diagnosed from 1998 to 2011 with 2 of the most frequent sex cord stromal tumors of the testis, including Leydig and Sertoli cell tumors, were selected for study. Overall survival estimates were assessed by the Kaplan-Meier method., Results: Of the 79,120 cases of testicular cancer between 1998 and 2011, 315 (0.39%) were primary malignant Leydig or Sertoli cell tumors. Median patient age was 43 years for both tumors. Of the 315 patients 250 (79%) had malignant Leydig cell tumors and 65 (21%) had malignant Sertoli cell tumors, of which 94% and 78%, respectively, were stage I. Overall survival at 1 and 5 years for stage I Leydig cell tumors was 98% (95% CI 96-100) and 91% (95% CI 85-96), and for stage I Sertoli cell tumors overall survival was 93% (95% CI 83-100) and 77% (95% CI 62-95), respectively (p = 0.015). Of patients with stage I Leydig and Sertoli cell tumors 94% and 84%, respectively, received no further treatment following orchiectomy., Conclusions: Five-year survival estimates of stage I Leydig and Sertoli cell tumors are significantly lower compared to those of stage I germ cell tumors with Sertoli cell tumors significantly worse than Leydig cell tumors. These differences in the survival of sex cord stromal tumors indicate the importance of large databases to evaluate the efficacy of treatment for rare neoplasms., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Active surveillance is an important alternative to definitive therapy for men with low risk prostate cancer. However, the impact of active surveillance on health related quality of life compared to that in men without cancer remains unknown. In this study we evaluated health related quality of life outcomes in men on active surveillance compared to men followed after negative prostate needle biopsy., Materials and Methods: A prospective study was conducted on men who were enrolled into the Center for Prostate Disease Research Multicenter National Database and underwent prostate needle biopsy for suspicion of prostate cancer between 2007 and 2014. Health related quality of life was assessed at biopsy (baseline) and annually for up to 3 years using SF-36 and EPIC questionnaires. Health related quality of life scores were modeled using generalized estimating equations, adjusting for baseline health related quality of life, and demographic and clinical characteristics., Results: Of the 1,204 men who met the initial eligibility criteria 420 had a negative prostate needle biopsy (noncancer comparison group). Among the 411 men diagnosed with low risk prostate cancer 89 were on active surveillance. Longitudinal analysis revealed that for most health related quality of life subscales there were no significant differences between the groups in adjusted health related quality of life score trends over time., Conclusions: In this study most health related quality of life outcomes in patients with low risk prostate cancer on active surveillance did not differ significantly from those of men without prostate cancer. A comparison group of men with a similar risk of prostate cancer detection is critical to clarify the psychological and physical impact of active surveillance., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We determined whether the characteristics of patients undergoing prostate needle biopsies and prostate needle biopsy results changed after the U.S. Preventive Services Task Force recommendation in 2012 against prostate specific antigen based screening for prostate cancer for men of any age., Materials and Methods: A prospective database of patients undergoing prostate needle biopsies at Virginia Mason from 2004 to 2014 was reviewed. Welch's t-test and chi-square tests were used to compare patients seen before to those seen after the USPSTF recommendation. Relative risks and corresponding confidence intervals were estimated by general linear regression., Results: Patients in the post-USPSTF group (310) had a higher prostate specific antigen (p <0.001), were more likely to be diagnosed with higher clinical stage (2b, p=0.003; 2c-3a, p=0.027) and D'Amico high risk prostate cancer (p=0.036), with an adjusted relative risk for high risk prostate cancer of 1.25 (95% CI 1.02-1.52) compared to those in the pre-USPSTF group (1,416). Limiting the pre-USPSTF group to the 30 months before the draft guidelines (448 patients) yielded similar results. The absolute number of biopsies performed decreased by 31%, with the majority of the decrease occurring in the detection of intermediate risk tumors., Conclusions: In the 2 and a half years after the USPSTF recommendation against prostate specific antigen based screening, patients undergoing prostate needle biopsies were significantly more likely to be diagnosed with high risk disease. However, a reduction in the number of prostate needle biopsies performed occurred concomitantly with a decrease in the detection of intermediate risk, potentially curable prostate cancer. Future focus on informed application of screening techniques may prevent the reversal of decades of improvement in the prostate cancer mortality rate., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Renal autotransplantation is an infrequently performed procedure. It has been used to manage complex ureteral disease, vascular anomalies and chronic kidney pain. We reviewed our 27-year experience with this procedure., Materials and Methods: This is a retrospective, observational study of 51 consecutive patients who underwent renal autotransplantation, including 29 at Oregon Health and Science University between 1986 and 2013, and 22 at Virginia Mason Medical Center between 2007 and 2012. Demographics, indications, operative details and followup data were collected. Early (30 days or less) and late (greater than 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model., Results: The 51 patients underwent a total of 54 renal autotransplants. Median followup was 21.5 months. The most common indications were loin pain hematuria syndrome/chronic kidney pain in 31.5% of cases, ureteral stricture in 20.4% and vascular anomalies in 18.5%. Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. Median operative time was 402 minutes and median length of stay was 6 days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early, high grade complications (grade IIIa or greater) developed in 14.8% of patients and 12.9% experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). Of patients who underwent autotransplantation for chronic kidney pain 35% experienced recurrence and 2 underwent transplant nephrectomy. No predictors of pain recurrence were identified., Conclusions: The most common indications for renal autotransplantation were loin pain hematuria syndrome/chronic kidney pain, ureteral stricture and vascular anomalies in descending order. Kidney function was preserved postoperatively and 2 graft losses occurred. At a median followup of 13 months pain resolved in 65% of patients who underwent the procedure. Complication rates compared favorably with those of other major urological operations and cold ischemia time was the only predictor of postoperative complications., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: To study the magnitude of radiation cystitis following radiation therapy for carcinoma cervix, and propose an algorithm to decide on early diversion, with or without vesicovaginostomy., Methods: Women who developed radiation cystitis following radiotherapy for carcinoma cervix from January 1998 to December 2011 were included in this retrospective study. Electronic hospital records were analysed to document the presence of radiation cystitis. All women who developed evidence of radiation-induced cystitis, according to the common toxicity and Radiation Therapy Oncology Group criteria, were included in the study. We looked at transfusion requirements, number of hospital admissions, quality of life and cost involved. Chi-square tests were done where applicable. SPSS version 16 was used for analysis., Results: Of the 902 patients who received radiation for carcinoma cervix in the 13-year period, 62 (6.87%) developed grade 3/4 cystitis. Twenty-eight of them underwent ileal conduit diversion, with 18 undergoing concomitant vesicovaginostomy. When compared with the patients who did not have diversion, the transfusion requirements, number of hospital admissions and quality of life had a statistically significant difference. Cost analysis of early diversion too showed a marginal benefit with early diversion. The limitation of the study was that it was retrospective in nature., Conclusion: In radiation cystitis, multiple hospital admissions and consequential increase in cost is the norm. In severe disease, early diversion is a prudent, cost-effective approach with good quality of life and early return to normal activity., (© 2014 Royal Australasian College of Surgeons.)

Urothelial cancers of the upper tract are aggressive malignancies with a propensity for distant metastases. Transitional cell carcinoma can also develop de novo in the ovaries and differentiation between these lesions requires immunohistochemistry. We report a case of right lower ureteric urothelial carcinoma with metastases to both ovaries. To our knowledge, this is the first reported case of bilateral ovarian metastases from an upper tract primary, diagnosed with immunohistochemistry.

Traditional treatment of upper tract transitional cell carcinoma (TCC) is nephroureterectomy with a bladder cuff. This is in keeping with the nature of the disease, in that TCC is a panurothelial disease. However, there are a few rare occasions when this would mean making a subject anephric, as in a TCC in a solitary kidney or bilateral synchronous/metachronous disease. We present a case of a patient with a dysplastic, poorly functioning left kidney and with a TCC of the ureter on the right side.

A case of primary hyperparathyroidism with bilateral renal staghorn calculi and brown tumor right thumb is reported in these images, along with the appropriate sequential management. Percutaneous nephrolithotomy (PCNL)was done after management of hypercalcemia and after parathyroidectomy. This case highlights the need for urologists and general practitioners to have a holistic approach in patient management., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Extramedullary haematopoiesis (EMH) is common in the spleen, liver and lymph nodes, or in para osseus sites. EMH in the adrenal is rare, with fewer than 10 cases reported. We report the case of a 40-year-old male who underwent laparoscopic adrenalectomy for an incidentally detected adrenal mass. The histology showed extramedullary hematopoesis. In patients with a known history of haemolytic anaemia, an enlarged adrenal gland in an asymptomatic individual could represent extramedullary haematopoesis. A confirmatory biopsy would be all that is necessary to avoid adrenalectomy.

Retropneumoperitoneum due to duodenal perforation after endoscopic retrograde cholangiopancreatography is rare. Recognizing the presence of free air, which outlines the right kidney, is essential for its early diagnosis and appropriate management., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Introduction: Fungal infections in the immunocompromised host are fairly common. Of the mycoses, Fusarium species are an emerging threat. Fusarium infections have been reported in solid organ transplants, with three reports of the infection in patients who had received renal transplants. To the best of our knowledge, this is the first case of an isolated cutaneous lesion as the only form of infection., Case Presentation: We report the case of a 45-year-old South Indian man who presented with localized cutaneous Fusarium infection following a renal transplant., Conclusion: In an immunocompromised patient, even an innocuous lesion needs to be addressed with the initiation of prompt treatment.

Primary localised amyloidosis involving the retroperitoneum is a rare disease. We report a 71-year-old diabetic man who presented with generalised fatigue, malaise and elevated serum creatinine. Investigations confirmed obstructive uropathy secondary to a retroperitoneal mass behind the urinary bladder, causing extrinsic compression of both the ureters, resulting in bilateral hydroureteronephrosis. Following initial bilateral percutaneous nephrostomies to stabilise renal function, a computed tomography-guided biopsy of the pelvic lesion which was done, was suggestive of amyloidosis. We present this case due to the rarity of localised retroperitoneal amyloidosis as a cause of obstructive uropathy.

Malignant small cell neuroendocrine tumors of the pelvi-calyceal system are rare, and even more uncommon is their occurrence with concomitant transitional cell carcinoma, in the same renal unit. We present such a case for its unique presentation.