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ObjectivesTo assess the adverse impact of the first 5 months of androgen deprivation therapy on body composition, physical performance, cardiometabolic health and health-related quality-of-life in prostate cancer patients.Materials and MethodsThirty-four prostate cancer patients (70 +/- 7 years) were assessed shortly after initiation of androgen deprivation therapy and again 5 months thereafter. Measurements consisted of whole-body dual-energy x-ray absorptiometry (body composition), computed tomography scanning of the upper leg (muscle mass), one-repetition maximum leg press (muscle strength), cardiopulmonary exercise testing (aerobic capacity), blood draws (metabolic parameters), accelerometry (habitual physical activity) and questionnaires (health-related quality-of-life). Data were analyzed with Student's paired t-tests.ResultsOver time, whole-body fat mass (from 26.2 +/- 7.7 to 28.4 +/- 8.3 kg, p < 0.001) and fasting insulin (from 9.5 +/- 5.8 to 11.3 +/- 6.9 mU/L, p < 0.001) increased. Declines were observed for quadriceps cross-sectional area (from 66.3 +/- 9.1 to 65.0 +/- 8.5 cm(2), p < 0.01), one-repetition maximum leg press (from 107 +/- 27 to 100 +/- 27 kg, p < 0.01), peak oxygen uptake (from 23.2 +/- 3.7 to 20.3 +/- 3.4 mL/min/kg body weight, p < 0.001), step count (from 7,048 +/- 2,277 to 5,842 +/- 1,749 steps/day, p < 0.01) and health-related quality-of-life (from 84.6 +/- 13.5 to 77.0 +/- 14.6, p < 0.001).ConclusionsAndrogen deprivation therapy induces adverse changes in body composition, muscle strength, cardiometabolic health and health-related quality-of-life already within 5 months after the start of treatment, possibly largely contributed by diminished habitual physical activity. Prostate cancer patients should, therefore, be stimulated to increase their habitual physical activity immediately after initiation of androgen deprivation therapy, to limit adverse side-effects and to improve health-related quality-of-life.

Item does not contain fulltext Aim: Timing of radium-223 (Ra-223) in metastatic castration-resistant prostate cancer (mCRPC) remains challenging due to alternative options and short window of opportunity. Methods: Ra-223 treated patients in the CAPRI-registry were included. Outcomes were evaluated based on treatment line of Ra-223. Results: Out of 285 patients, 49% received Ra-223 in line >/=3. 51% completed six Ra-223 injections and 34% had a symptomatic skeletal event after first Ra-223 without differences between subgroups. After correction of known prognostic factors Ra-223 in line >/=3 (HR: 3.267; 95% CI: 1.689-6.317; p < 0.01) remained associated with worse OS. Conclusion: In the Netherlands, Ra-223 was mainly started as second or third mCRPC-treatment in 2014-2018. Later timing of Ra-223 did affect OS, but not treatment completion and occurrence of symptomatic skeletal events.

Background Open radical cystectomy (ORC) is regarded as the standard treatment for muscle-invasive bladder cancer, but robot-assisted radical cystectomy (RARC) is increasingly used in practice. A recent study showed that RARC resulted in slightly fewer minor but slightly more major complications, although the difference was not statistically significant. Some differences were found in secondary outcomes favouring either RARC or ORC. RARC use is expected to increase in coming years, which fuels the debate about whether RARC provides value for money. Objective To assess the cost-effectiveness of RARC compared to ORC in bladder cancer. Design, setting, and participants This economic evaluation was performed alongside a prospective multicentre comparative effectiveness study. We included 348 bladder cancer patients (ORC, n = 168; RARC, n = 180) from 19 Dutch hospitals. Outcome measurements and statistical analysis Over 1 yr, we assessed the incremental cost per quality-adjusted life year (QALY) gained from both healthcare and societal perspectives. We used single imputation nested in the bootstrap percentile method to assess missing data and uncertainty, and inverse probability of treatment weighting to control for potential bias. Deterministic sensitivity analyses were performed to explore the impact of various parameters on the cost difference. Results and limitations The mean healthcare cost per patient was €17 141 (95% confidence interval [CI] €15 791–€18 720) for ORC and €21 266 (95% CI €19 163–€23 650) for RARC. The mean societal cost per patient was €18 926 (95% CI €17 431–€22 642) for ORC and €24 896 (95% CI €21 925–€31 888) for RARC. On average, RARC patients gained 0.79 QALYs (95% CI 0.74–0.85) compared to 0.81 QALYs (95% CI 0.77–0.85) for ORC patients, resulting in a mean QALY difference of −0.02 (95% CI −0.05 to 0.02). Using a cost-effectiveness threshold of €80 000, RARC was cost-effective in 0.6% and 0.2% of the replications for the healthcare and societal perspectives, respectively. Conclusions RARC shows no difference in terms of QALYs, but is more expensive than ORC. Hence, RARC does not seem to provide value for money in comparison to ORC. Patient summary This study assessed the relation between costs and effects of robot-assisted surgery compared to open surgery for removal of the bladder in 348 Dutch patients with bladder cancer. We found that after 1 year, the two approaches were similarly effective according to a measure called quality-adjusted life years, but robot-assisted surgery was much more expensive. This trial was prospectively registered in the Netherlands Trial Register as NTR5362 ( https://www.trialregister.nl/trial/5214 ).

Background: Radical cystectomy with pelvic lymph node dissection (PLND) and urinary diversion in patients with bladder cancer is known for its high risk of complications. Although open radical cystectomy (ORC) is regarded as the standard treatment, robot-assisted radical cystectomy (RARC) is increasingly used in practice, despite the fact that high-quality evidence comparing the effectiveness of both techniques is lacking.Objective: To study the effectiveness of RARC compared with that of ORC, in terms of 90 d complications (Clavien-Dindo), health-related quality of life (HRQOL), and clinical outcomes.Design, setting, and participants: A prospective comparative effectiveness study was conducted in 19 Dutch centres, expert in either ORC or RARC. Follow-up visits were scheduled at 30, 90, and 365 d.Intervention: Standard ORC or RARC with PLND, using a standardised perioperative protocol. Outcome measurements and statistical analysis: The primary outcome was any-grade complications after 90 d. Secondary outcomes included HRQOL, complications (minor, major, 30 d, and 365 d), and clinical outcomes. Differences were calculated as risk differences (RDs) between the groups with 95% confidence intervals (CIs), adjusted for potential baseline differences by means of propensity score–based inverse probability of treatment weighting.Results and limitations: Between March 2016 and November 2018, 348 patients were included (n = 168 for ORC, n = 180 for RARC). At 90 d, any-grade complication rates were 63% for ORC and 56% for RARC (RD –6.4%, 95% CI –17 to 4.5). Major complication rates were 15% for ORC and 16% for RARC (RD 0.9%, 95% CI –7.0 to 8.8). Total minor complication rates were 57% for ORC and 49% for RARC (RD –7.6%, 95% CI –19 to 3.6). Analyses showed no statistically significant differences in HRQOL between ORC and RARC. Some differences were found in the secondary outcomes in favour of either RARC or ORC. The major drawback inherent to the design comprises residual confounding.Conclusions: This multicentre comparative effectiveness study showed no statistically significant differences between ORC and RARC in terms of complications and HRQOL.Patient summary: This multicentre study did not show differences in overall complication rates, health-related quality of life, mortality, and clinical and oncological outcomes between open and robot-assisted radical cystectomy in bladder cancer patients.

Background Non-muscle-invasive bladder cancer (NMIBC) is the most common neoplasm of the urinary tract and requires life-long invasive surveillance to detect disease recurrence. Currently, there are no effective oral therapies that delay disease recurrence or progression. We recently demonstrated that in mice, metformin accumulates unchanged in the urine. Urothelial cells are exposed to metformin concentrations ~ 240-fold higher than in serum. This was effective in the treatment of mouse bladder cancer models. Methods We describe the protocol of a multi-centre, open-label, phase II clinical trial of metformin in up to 49 evaluable patients with intermediate-risk NMIBC with the aim to determine the overall response to administration of oral metformin for 3 months on a marker tumour deliberately left following transurethral resection of multiple, papillary NMIBC tumours. All patients will receive metformin orally at doses up to 3000 mg per day. Metformin treatment will start within 2 weeks following transurethral resection of all tumours except one marker lesion. After 3 months of metformin treatment, the effect of metformin on the marker lesion is evaluated by cystoscopy and biopsy under anaesthesia. Residual tumour, if present at this evaluation, will be resected. In case of complete disappearance of the marker lesion, the former tumour area will be biopsied. The primary outcome is the complete response rate of the marker lesion, as determined by decentralised scoring of pre- and post-treatment cystoscopy images by expert independent urologists. Secondary outcomes are the partial response rate, overall safety of metformin and the duration of the time to recurrence. Discussion Preclinical studies show the potential role of oral metformin treatment in the management of NMIBC. It could offer an alternative to current adjuvant intravesical treatment. If positive, the reported results of this study could warrant further phase III trials to compare the efficacy of metformin against current treatments of intravesical installations with chemotherapy or Bacillus Calmette-Guérin (BCG). Trial registration This trial is registered in ClinicalTrials.gov under NCT03379909.

With an increasing life expectancy, more and more men will be at risk of developing prostate cancer in a larger prostate. Surgical treatment of these large glands is challenging due to impaired visualisation with a reduced overview of the surgical plane and limited working space combined with reduced options for intra-operative manipulation of these prostates. This in turn can result in prolonged operative times, increased blood loss, poor nerve sparing and apical dissection, and a higher chance of other complications.

Objective To determine the impact of the European Randomized Study of Screening for Prostate Cancer (ERSPC) publication in 2009 on prostate-specific antigen (PSA) level testing by Dutch general practitioners (GPs) in men aged ≥40 years. Materials and Methods Retrospective study with a Dutch insurance company database (containing PSA test claims) and a large district hospital-laboratory database (containing PSA-test results). The difference in primary PSA-testing rate as well as follow-up testing before and after the ERSPC was tested using the chi-square test with statistical significance at P < 0.05. Results Decline in PSA tests 4 months after ERSPC publication, especially for men aged ≥60 years. Primary testing as well as follow-up testing decreased, both for PSA levels of 10 ng/mL moderately increased (P = 0.171). Referral to a urologist after a PSA level result of >4 ng/mL decreased slightly after the ERSPC publication (P = 0.044). Conclusions After the ERSPC publication primary PSA testing as well as follow-up testing decreased. Follow-up testing seemed not to be adequate after an abnormal PSA result. The reasons for this remain unclear.

Macrodystrophia lipomatosa is a rare disease that causes congenital local gigantism of part of an extremity, which is characterised by an increase in all mesenchymal elements, particularly fibroadipose tissue. This is the first report to our knowledge of a case of histologically confirmed bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

Patients diagnosed with steal syndrome after hemodialysis access surgery have a few options for symptom relief while maintaining vascular access. These include fistula lengthening, banding, distal revascularization with interval ligation (DRIL), revision using distal inflow (RUDI) or proximalization of the arterial inflow (PAI). Two cases are described in which a modified DRIL procedure without interval ligation was used to relieve steal syndrome, leaving the arterial supply of an ischemic hand not entirely dependent upon a bypass. Furthermore, a review of the literature is presented in order to elucidate this relatively new treatment option as a viable means to improve hand perfusion while maintaining a functional fistula.

To determine the impact of the European Randomized Study of Screening for Prostate Cancer (ERSPC) publication in 2009 on prostate-specific antigen (PSA) level testing by Dutch general practitioners (GPs) in men aged ≥40 years.Retrospective study with a Dutch insurance company database (containing PSA test claims) and a large district hospital-laboratory database (containing PSA-test results). The difference in primary PSA-testing rate as well as follow-up testing before and after the ERSPC was tested using the chi-square test with statistical significance at P0.05.Decline in PSA tests 4 months after ERSPC publication, especially for men aged ≥60 years. Primary testing as well as follow-up testing decreased, both for PSA levels of4 ng/mL as well as for PSA levels of 4-10 ng/mL. Follow-up testing after a PSA level result of10 ng/mL moderately increased (P = 0.171). Referral to a urologist after a PSA level result of4 ng/mL decreased slightly after the ERSPC publication (P = 0.044).After the ERSPC publication primary PSA testing as well as follow-up testing decreased. Follow-up testing seemed not to be adequate after an abnormal PSA result. The reasons for this remain unclear.

Background Prostate specific antigen (PSA) testing is widely used, but guidelines on follow-up are unclear. Methods We performed a systematic review of the literature to determine follow-up policy after PSA testing by general practitioners (GPs) and non-urologic hospitalists, the use of a cut-off value for this policy, the reasons for repeating a PSA test after an initial normal result, the existence of a general cut-off value below which a PSA result is considered normal, and the time frame for repeating a test. Data sources. MEDLINE, Embase, PsychInfo and the Cochrane library from January 1950 until May 2011. Study eligibility criteria. Studies describing follow-up policy by GPs or non-urologic hospitalists after a primary PSA test, excluding urologists and patients with prostate cancer. Studies written in Dutch, English, French, German, Italian or Spanish were included. Excluded were studies describing follow-up policy by urologists and follow-up of patients with prostate cancer. The quality of each study was structurally assessed. Results Fifteen articles met the inclusion criteria. Three studies were of high quality. Follow-up differed greatly both after a normal and an abnormal PSA test result. Only one study described the reasons for not performing follow-up after an abnormal PSA result. Conclusions Based on the available literature, we cannot adequately assess physicians’ follow-up policy after a primary PSA test. Follow-up after a normal or raised PSA test by GPs and non-urologic hospitalists seems to a large extent not in accordance with the guidelines.