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INTRODUCTION AND AIMS: The optimal approach for nephroureterectomy in patients with suspected UTUC remains a point of debate. In this review, we compare the oncological outcomes of robotic nephroureterectomy (RNU) with open (ONU) or laparoscopic nephroureterectomy (LNU). METHODS: All randomized trials and observational studies comparing RNU with ONU and/or LNU for suspected non-metastatic UTUC are included in this review. The systematic review was performed in accordance with the Cochrane Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The primary outcome measures were overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and intravesical recurrence-free survival (IV-RFS). The secondary outcome measures were the lymph node dissection (LND) rates, positive margin rates, and the proportion of patients receiving bladder intravesical chemotherapy. RESULTS: We identified 8172 references through our electronic searches and 8 studies through manual searching. A total of 15 studies met the inclusion criteria. The total number of patients in the review was 18,964. RNU had superior OS compared to LNU (HR: 0.81 (95% CI: 0.71, 0.93), p-0.002 (very low certainty)). RNU and ONU had similar OS (HR: 0.83 (95% CI: 0.52, 1.34), p-0.44 (very low certainty)). One study reported an independent association of RNU as a worse predictor of IV-RFS when compared to ONU (HR-1.73 (95% CI: 1.22, 2.45)). The LND rates were higher in the RNU cohort when compared to the LNU cohort (RR 1.24 (95% CI: 1.03, 1.51), p-0.03 (low certainty)). The positive margin rate was lower in the RNU cohort when compared to the ONU cohort (RR 0.29 (95% CI: 0.08, 0.86), p-0.03 (low certainty)). CONCLUSION: RNU offers comparable oncological efficacy to ONU, except for intravesical recurrence-free survival (IV-RFS). RNU has fewer positive surgical margin rates compared to ONU in well-balanced studies. RNU appears to outperform LNU for certain oncological parameters, such as OS and the proportion of patients who receive lymph node dissections. The quality of evidence comparing surgical techniques for UTUC has remained poor in the last decade.

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Patients with high-risk and advanced prostate cancer require safe and efficacious therapies likely to offer a survival advantage while minimizing the treatment-related toxicities. Improvements in the surgical technology, diagnostic modalities, radiological staging, and risk stratification have made surgery for high-risk and advanced prostate cancer a safe and feasible option. In this review, we outline the role of radical prostatectomy in high-risk localized, locally advanced, and metastatic prostate cancer. We overview available data evaluating the use of surgery in the context of a multi-modal approach and highlight ongoing trials in this area. Furthermore, the role of surgery as a non-systemic modality for metastasis-directed therapy (MDT) is also described. Emerging imaging modalities enabling more accurate staging and longer follow-up of clinical trials for prognostic endpoints are anticipated to help identify patient cohorts and treatment strategies, where the use of surgical treatments is likely to provide oncological benefits and acceptable toxicity.

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OBJECTIVE: This study aimed to identify the complication rate, specifically bleeding, in patients who received anticoagulation undergoing intravesical botulinum toxin A injections. MATERIAL AND METHODS: This study included all patients (n=430) undergoing intravesical injection of botulinum toxin A in a single secondary care center between January 2013 and December 2018. We recorded the use of anticoagulants/antiplatelets and complications. Logistic regression was used to investigate the association between anticoagulant/antiplatelet use and the complications arising, while controlling for age and sex. RESULTS: We identified 430 procedures in 94 men and 336 women (mean age, 60 years). A total of 79 patients received anticoagulants (18%). Aspirin was the most common anticoagulant (52%). Complication rate in anticoagulated patients was 6% (n=5), and it was 2% in those not on anticoagulants/antiplatelets (n=7). Complications were over 3 times more likely in patients who received anticoagulants/antiplatelets (odds ratio=3.233; 95% confidence interval=0.873, 11.38; p=0.067). There was no difference in the complications between patients with idiopathic symptoms and those with neuropathic overactive bladder. No patients required further surgical intervention, and all except 1 were Clavien-Dindo grade I-II with no mortalities. CONCLUSION: Anticoagulated patients undergoing intravesical injections have higher complication risks; however, the treatment outcome is unaffected with no significant morbidity/mortality. This is the first study to demonstrate safe outcomes for this subgroup and can assist in decision making and consenting.

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OBJECTIVE: To assess the content validity of a low-cost bench-top model ("Raj Model") for the training of laparoscopic port insertion at the Urology Simulation Bootcamp course (USBC). MATERIALS AND METHODS: A low-cost abdominal wall model of 40 × 40 cm was created to simulate laparoscopic port placement. The model was made using different synthetic materials to represent layers (skin-vinyl sheet, subcutaneous fat-10 mm soft foam, anterior rectus sheath and muscle-floor mat, posterior rectus sheath-masking wall tape, peritoneum-sellotape). Each model was used by up to 3 trainees to practise laparoscopic port placement. The model was assessed for content validity by trainees and experts using a 5-point Likert scale. RESULT: In total, 88 trainees and 6 experts participated in the study. For all aspects of the synthetic abdominal wall, good (4) or very good (5) scores ranged from 52.7-69.2%, whereas very poor (1) rating ranged from 0 to 4.3%. There was no significant difference in responses for the content validity of the model between trainees and experts. There was a high intraclass correlation amongst responses from trainees (0.89) and experts (0.79). Approximately 76.3% of trainees and experts felt that the model is suitable for training. CONCLUSION: This is the first validation study of a low-cost abdominal wall model for teaching laparoscopic port placement for trainees. Our study demonstrates that this synthetic model has high content validity and is useful for surgical training.

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BACKGROUND: The aim of this work was to assess the use of prostate-specific membrane antigen (PSMA)-labelled radiotracers in detecting the recurrence of prostate cancer. PSMA is thought to have higher detection rates when utilized in positron emission tomography (PET)/computed tomography (CT) scans, particularly at lower prostate-specific antigen (PSA) levels, compared with choline-based scans. METHODS: A systematic review was conducted comparing choline and PSMA PET/CT scans in patients with recurrent prostate cancer following an initial curative attempt. The primary outcomes were overall detection rates, detection rates at low PSA thresholds, difference in detection rates and exclusive detection rates on a per-person analysis. Secondary outcome measures were total number of lesions, exclusive detection by each scan on a per-lesion basis and adverse side effects. RESULTS: Overall detection rates were 79.8% for PSMA and 66.7% for choline. There was a statistically significant difference in detection rates favouring PSMA [OR (M-H, random, 95% confidence interval (CI)) 2.27 (1.06, 4.85), p = 0.04]. Direct comparison was limited to PSA < 2 ng/ml in two studies, with no statistically significant difference in detection rates between the scans [OR (M-H, random, 95% CI) 2.37 (0.61, 9.17) p = 0.21]. The difference in detection on the per-patient analysis was significantly higher in the PSMA scans (p < 0.00001). All three studies reported higher lymph node, bone metastasis and locoregional recurrence rates in PSMA. CONCLUSIONS: PSMA PET/CT has a better performance compared with choline PET/CT in detecting recurrent disease both on per-patient and per-lesion analysis and should be the imaging modality of choice while deciding on salvage and nonsystematic metastasis-directed therapy strategies.

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OBJECTIVE: To establish the pattern of isotope bone scan (BS) positivity in a large contemporaneous cohort of patients with newly diagnosed localised prostate cancer and compare with the European Association of Urology (EAU) guidelines, as imaging guidelines and clinical practice for using BS to stage newly diagnosed patients with intermediate-risk localised prostate cancer are not uniform in the literature. PATIENTS AND METHODS: All patients with newly diagnosed prostate cancer were discussed in a specialist multidisciplinary team meeting and were prospectively entered in a database. Patients were categorised based on D'Amico classification. All intermediate- and high-risk patients had pelvic magnetic resonance imaging and BS unless contraindicated. The BS positivity in each group was analysed and the negative predictive value (NPV) calculated. A cohort of 2720 patients between 2002 and 2015 was retrospectively analysed. RESULTS: Of 976 patients in the D'Amico intermediate-risk category, 99 had primary Gleason pattern 4. Only one of the 99 patients had a positive BS and there were no positive BS in patients with Gleason primary pattern 3 in the intermediate-risk category. On subgroup analysis, based on prostate-specific antigen (PSA) level and Gleason grade alone, the BS-positivity rate in patients with a PSA level of <20 ng/mL and Gleason primary pattern 4 vs 3 was 6% and 0%, respectively, resulting in 100% NPV for a positive BS with Gleason primary pattern 3 and a PSA level of <20 ng/mL. The importance of clinical T stage (cT) was also noted, as eight of 146 patients had positive BS, who were high risk on cT stage, with a PSA level of <20 ng/mL and Gleason score <8. All eight patients had Gleason primary pattern 4. By limiting BS to the population at risk (all high-risk + intermediate-risk with primary pattern 4), 68 BS per year could have been avoided in a single centre. A limitation was that there was no histological confirmation of bony metastases. Extending the BS recommendation considering the new Gleason Grade Grouping is discussed. CONCLUSION: This study confirms that a staging BS can be safely avoided in patients with intermediate-risk prostate cancer with Gleason primary pattern 3 and to limit performing BS in all high-risk prostate cancer and in the intermediate-risk group when the primary Gleason pattern is 4, thereby reinforcing the current recommendations of the EAU guidelines.

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PURPOSE: To compare the efficacy of sublingual piroxicam 40 mg with intramuscular diclofenac 75 mg in treatment of acute renal colic. The secondary objective was to look for factors that can affect the severity of the pain and pain relief in acute renal colic. MATERIALS AND METHODS: One hundred patients with acute renal colic were randomized into two groups. Group A (n = 50) received intramuscular diclofenac and sublingual methylcobalamin. Group B (n = 50) received sublingual piroxicam 40 mg and intramuscular distilled water. Pain severity was measured using Visual Analog Scale (VAS) and verbal and facial response scales. They were followed up for 3 h. Intramuscular injection of pentazocine 30 mg with promethazine 25 mg were used as rescue drugs. RESULTS: Both groups were comparable for age, sex distribution, body mass index (BMI), and pain duration before presentation. Significant pain relief was noticed in both groups. Sixteen percent in group A and 18% in group B had complete pain relief within 30 min (P = .75). Fifteen patients in group A and 13 patients in group B needed rescue drugs, 84% of group A and 76% of group B had complete pain relief at the end of 3 hours (P = .25). Decrease in pain by each scoring method was also comparable (P = .75). In multiple regression analysis, increasing age, positively affects the severity of pain and pain relief while increasing BMI negatively affect the initial pain relief. Acute renal colic seems to affect men more commonly than women, 81% of the study population were men. Patients with low initial pain score did not require any additional pain relief. Average pain duration before presenting to hospital is 260 min. Sixty percent of renal colics are due to stones below pelvic brim. CONCLUSION: The results show that sublingual piroxicam is as effective as intramuscular diclofenac. It can be easily self-administered and it overcomes the morbidity and time delay in getting intramuscular diclofenac.

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Eosinophilic colitis is an uncommon condition and rarely presents as acute abdomen. We report a 65-year-old man who presented with acute abdomen-- severe pain in upper abdomen, with pyrexia, tachycardia, guarding and right-sided intercostal tenderness--secondary to eosinophilic colitis and was successfully managed. He had additional problems in form of cirrhosis, chronic hepatitis, cholangitis, pyogenic liver abscesses and gout.

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