Axel S. Merseburger

EAU Guidelines on Renal Cell Carcinoma: 2014 Update.

CONTEXT The European Association of Urology Guideline Panel for Renal Cell Carcinoma (RCC) has prepared evidence-based guidelines and recommendations for RCC management. OBJECTIVES To provide an update of the 2010 RCC guideline based on a standardised methodology that is robust, transparent, reproducible, and reliable. EVIDENCE ACQUISITION For the 2014 update, the panel prioritised the following topics: percutaneous biopsy of renal masses, treatment of localised RCC (including surgical and nonsurgical management), lymph node dissection, management of venous thrombus, systemic therapy, and local treatment of metastases, for which evidence synthesis was undertaken based on systematic reviews adhering to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Relevant databases (Medline, Cochrane Library, trial registries, conference proceedings) were searched (January 2000 to November 2013) including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm. Risk of bias (RoB) assessment and qualitative and quantitative synthesis of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. EVIDENCE SYNTHESIS All chapters of the RCC guideline were updated. For the various systematic reviews, the search identified a total of 10,862 articles. A total of 151 studies reporting on 78,792 patients were eligible for inclusion; where applicable, data from RCTs were included and meta-analyses were performed. For RCTs, there was low RoB across studies; however, clinical and methodological heterogeneity prevented data pooling for most studies. The majority of studies included were retrospective with matched or unmatched cohorts based on single or multi-institutional data or national registries. The exception was for systemic treatment of metastatic RCC, in which several RCTs have been performed, resulting in recommendations based on higher levels of evidence. CONCLUSIONS The 2014 guideline has been updated by a multidisciplinary panel using the highest methodological standards, and provides the best and most reliable contemporary evidence base for RCC management. PATIENT SUMMARY The European Association of Urology Guideline Panel for Renal Cell Carcinoma has thoroughly evaluated available research data on kidney cancer to establish international standards for the care of kidney cancer patients.

GuidelinesEAU Guidelines on Renal Cell Carcinoma: The 2010 Update

CONTEXT AND OBJECTIVES The European Association of Urology Guideline Group for renal cell carcinoma (RCC) has prepared these guidelines to help clinicians assess the current evidence-based management of RCC and to incorporate the present recommendations into daily clinical practice. EVIDENCE ACQUISITION The recommendations provided in the current updated guidelines are based on a thorough review of available RCC guidelines and review articles combined with a systematic literature search using Medline and the Cochrane Central Register of Controlled Trials. EVIDENCE SYNTHESIS A number of recent prospective randomised studies concerning RCC are now available with a high level of evidence, whereas earlier publications were based on retrospective analyses, including some larger multicentre validation studies, meta-analyses, and well-designed controlled studies. CONCLUSIONS These guidelines contain information for the treatment of an individual patient according to a current standardised general approach. Updated recommendations concerning diagnosis, treatment, and follow-up can improve the clinical handling of patients with RCC.

Treatment of Muscle-Invasive and Metastatic Bladder Cancer: Update of the EAU Guidelines.

CONTEXT New data regarding treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. OBJECTIVE To review the new EAU guidelines for MiM-BC with a specific focus on treatment. EVIDENCE ACQUISITION New literature published since the last update of the EAU guidelines in 2008 was obtained from Medline, the Cochrane Database of Systematic Reviews, and reference lists in publications and review articles and comprehensively screened by a group of urologists, oncologists, and a radiologist appointed by the EAU Guidelines Office. Previous recommendations based on the older literature on this subject were also taken into account. Levels of evidence (LEs) and grades of recommendations (GRs) were added based on a system modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SYNTHESIS Current data demonstrate that neoadjuvant chemotherapy in conjunction with radical cystectomy (RC) is recommended in certain constellations of MiM-BC. RC remains the basic treatment of choice in localised invasive disease for both sexes. An attempt has been made to define the extent of surgery under standard conditions in both sexes. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. In contrast to neoadjuvant chemotherapy, current advice recommends the use of adjuvant chemotherapy only within clinical trials. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for medical or personal reasons. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin remains cisplatin-containing combination chemotherapy. With the advent of vinflunine, second-line chemotherapy has become available. CONCLUSIONS In the treatment of localised invasive bladder cancer (BCa), the standard treatment remains radical surgical removal of the bladder within standard limits, including as-yet-unspecified regional lymph nodes. However, the addition of neoadjuvant chemotherapy must be considered for certain specific patient groups. A new drug for second-line chemotherapy (vinflunine) in metastatic disease has been approved and is recommended.

The updated EAU guidelines on muscle-invasive and metastatic bladder cancer.

CONTEXT New data regarding diagnosis and treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. OBJECTIVE To review the new EAU guidelines for MiM-BC. EVIDENCE ACQUISITION A comprehensive workup of the literature obtained from Medline, the Cochrane central register of systematic reviews, and reference lists in publications and review articles was developed and screened by a group of urologists, oncologists, and radiologist appointed by the EAU Guideline Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SYNTHESIS The diagnosis of muscle-invasive bladder cancer (BCa) is made by transurethral resection (TUR) and following histopathologic evaluation. Patients with confirmed muscle-invasive BCa should be staged by computed tomography (CT) scans of the chest, abdomen, and pelvis, if available. Adjuvant chemotherapy is currently only advised within clinical trials. Radical cystectomy (RC) is the treatment of choice for both sexes, and lymph node dissection should be an integral part of cystectomy. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for clinical or personal reasons. An appropriate schedule for disease monitoring should be based on (1) natural timing of recurrence, (2) probability of disease recurrence, (3) functional deterioration at particular sites, and (4) consideration of treatment of a recurrence. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin is cisplatin-containing combination chemotherapy. Presently, there is no standard second-line chemotherapy. CONCLUSIONS These EAU guidelines are a short, comprehensive overview of the updated guidelines of (MiM-BC) as recently published in the EAU guidelines and also available in the National Guideline Clearinghouse.

Impact of gender on bladder cancer incidence, staging, and prognosis

IntroductionWhile patient gender is an important factor in the clinical decision-making for the management of bladder cancer, there are minimal evidence-based recommendations to guide health care professionals. Recent epidemiologic and translational research has shed some light on the complex relationship between gender and bladder cancer. Our aim was to review the literature on the effect of gender on bladder cancer incidence, biology, mortality, and treatment.MethodsUsing MEDLINE, we performed a search of the literature between January 1975 and April 2011.ResultsAlthough men are nearly 3–4 times more likely to develop bladder cancer than women, women present with more advanced disease and have worse survival. Recently, a number of population-based and multicenter collaborative studies have shown that female gender is associated with a significantly higher rate of cancer-specific recurrence and mortality after radical cystectomy. The disparity between genders is proposed to be the result of a differences exposure to carcinogens (i.e., tobacco and chemicals) as well as reflective of genetic, anatomic, hormonal, societal, and environmental factors. Explanations for the differential behavior of bladder cancer between genders include sex steroids and their receptors as well as inferior quality of care for women (inpatient length of stay, referral patterns, and surgical outcomes).ConclusionsIt is imperative that health care practitioners and researchers from disparate disciplines collectively focus efforts to appropriately develop gender-specific evidence-based guidelines for bladder cancer patients. We must strive to develop multidisciplinary collaborative efforts to provide tailored gender-specific care for bladder cancer patients.

Histological verification of 11C-choline-positron emission/computed tomography-positive lymph nodes in patients with biochemical failure after treatment for localized prostate cancer.

To evaluate the potential of 11C‐choline‐positron emission tomography (PET)/computed tomography (CT) for planning surgery in patients with prostate cancer and prostate‐specific antigen (PSA) relapse after treatment with curative intent.

EAU Guidelines on Robotic and Single-site Surgery in Urology

CONTEXT This is a short version of the European Association of Urology (EAU) guidelines on robotic and single-site surgery in urology, as created in 2013 by the EAU Guidelines Office Panel on Urological Technologies. OBJECTIVE To evaluate current evidence regarding robotic and single-site surgery in urology and to provide clinical recommendations. EVIDENCE ACQUISITION A comprehensive online systematic search of the literature according to Cochrane recommendations was performed in July 2012, identifying data from 1990 to 2012 regarding robotic and single-site surgery in urology. EVIDENCE SYNTHESIS There is a lack of high-quality data on both robotic and single-site surgery for most upper and lower urinary tract operations. Mature evidence including midterm follow-up data exists only for robot-assisted radical prostatectomy. In the absence of high-quality data, the guidelines panels recommendations were based mostly on the review of low-level evidence and expert opinions. CONCLUSIONS Robot-assisted urologic surgery is an emerging and safe technology for most urologic operations. Further documentation including long-term oncologic and functional outcomes is deemed necessary before definite conclusions can be drawn regarding the superiority or not of robotic assistance compared with the conventional laparoscopic and open approaches. Laparoendoscopic single-site surgery is a novel laparoscopic technique providing a potentially superior cosmetic outcome over conventional laparoscopy. Nevertheless, further advantages offered by this technology are still under discussion and not yet proven. Due to the technically demanding character of the single-site approach, only experienced laparoscopic surgeons should attempt this technique in clinical settings. PATIENT SUMMARY This work represents the shortened version of the 2013 European Association of Urology guidelines on robotic and single-site surgery. The authors systematically evaluated published evidence in these fields and concluded that robotic assisted surgery is possible and safe for most urologic operations. Whilst laparoendoscopic single-site surgery is performed using the fewest incisions, the balance between risk and benefit is currently unclear. The evidence to support the conclusions in this guideline was generally poor, but best for robotic assisted radical prostatectomy. As such, these recommendations were based upon expert opinion, and further high-quality research is needed in this field.

Systematic Review and Meta-analysis of Diagnostic Accuracy of Percutaneous Renal Tumour Biopsy

CONTEXT The role of percutaneous renal tumour biopsy (RTB) remains controversial due to uncertainties regarding its diagnostic accuracy and safety. OBJECTIVE We performed a systematic review and meta-analysis to determine the safety and accuracy of percutaneous RTB for the diagnosis of malignancy, histologic tumour subtype, and grade. EVIDENCE ACQUISITION Medline, Embase, and Cochrane Library were searched for studies providing data on diagnostic accuracy and complications of percutaneous core biopsy (CB) or fine-needle aspiration (FNA) of renal tumours. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for diagnosis of malignancy. The Cohen kappa coefficient (κ) was estimated for the analysis of histotype/grade concordance between diagnosis on RTB and surgical specimen. Risk of bias assessment was performed (QUADAS-2). EVIDENCE SYNTHESIS A total of 57 studies recruiting 5228 patients were included. The overall median diagnostic rate of RTB was 92%. The sensitivity and specificity of diagnostic CBs and FNAs were 99.1% and 99.7%, and 93.2% and 89.8%, respectively. A good (κ = 0.683) and a fair (κ = 0.34) agreement were observed between histologic subtype and Fuhrman grade on RTB and surgical specimen, respectively. A very low rate of Clavien ≥ 2 complications was reported. Study limitations included selection and differential-verification bias. CONCLUSIONS RTB is safe and has a high diagnostic yield in experienced centres. Both CB and FNA have good accuracy for the diagnosis of malignancy and histologic subtype, with better performance for CB. The accuracy for Fuhrman grade is fair. Overall, the quality of the evidence was moderate. Prospective cohort studies recruiting consecutive patients and using homogeneous reference standards are required. PATIENT SUMMARY We systematically reviewed the literature to assess the safety and diagnostic performance of renal tumour biopsy (RTB). The results suggest that RTB has good accuracy in diagnosing renal cancer and its subtypes, and it appears to be safe. However, the quality of evidence was moderate, and better quality studies are required to provide a more definitive answer.

EAU Guidelines on Laser Technologies

CONTEXT The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice. OBJECTIVE Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice. EVIDENCE ACQUISITION Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified. EVIDENCE SYNTHESIS Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure. CONCLUSIONS In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.

Association of hyaluronic acid family members (HAS1, HAS2, and HYAL‐1) with bladder cancer diagnosis and prognosis

Cancer biomarkers are the backbone for the implementation of individualized approaches to bladder cancer (BCa). Hyaluronic acid (HA) and all 7 members of the HA family, that is, HA synthases (HA1, HA2, HA3), HYAL‐1 hyaluronidase, and HA receptors (CD44s, CD44v, and RHAMM), function in tumor growth and progression. However, the diagnostic and prognostic potential of these 7 HA family members has not been compared simultaneously in any cancer. We evaluated the diagnostic and prognostic potential of HA family members in BCa.