Bart De Troyer

Etiology of Urethral Stricture Disease in the 21st Century

PURPOSE We determined the current etiology of urethral stricture disease in the developed world and whether there are any differences in etiology by patient age and stricture site. MATERIAL AND METHODS Between January 2001 and August 2007 we prospectively collected a database on 268 male patients with urethral stricture disease who underwent urethroplasty at a referral center. The database was analyzed for possible cause of stricture and for previous interventions. Subanalysis was done for stricture etiology by patient age and stricture site. RESULTS The most important causes were idiopathy, transurethral resection, urethral catheterization, pelvic fracture and hypospadias surgery. Overall iatrogenic causes (transurethral resection, urethral catheterization, cystoscopy, prostatectomy, brachytherapy and hypospadias surgery) were the etiology in 45.5% of stricture cases. In patients younger than 45 years the main causes were idiopathy, hypospadias surgery and pelvic fracture. In patients older than 45 years the main causes were transurethral resection and idiopathy. In cases of penile urethra hypospadias surgery idiopathic stricture, urethral catheterization and lichen sclerosus were the main causes, while in the bulbar urethra idiopathic strictures were most prevalent, followed by strictures due to transurethral resection. The main cause of multifocal/panurethral anterior stricture disease was urethral catheterization, while pelvic fracture was the main cause of posterior urethral strictures. CONCLUSIONS Of strictures treated with urethroplasty today iatrogenic causes account for about half of the urethral stricture cases in the developed world. In about 1 of 3 cases no obvious cause could be identified. The etiology is significantly different in younger vs older patients and among stricture sites.

A Matched Control Analysis of Adjuvant and Salvage High-Dose Postoperative Intensity-Modulated Radiotherapy for Prostate Cancer

PURPOSE It is unclear whether immediate adjuvant radiotherapy for high-risk disease at prostatectomy (capsule perforation, seminal vesicle invasion, and/or positive surgical margins) is equivalent to delayed salvage radiotherapy at biochemical recurrence. We performed a matched case analysis comparing high-dose adjuvant intensity modulated radiotherapy (A-IMRT) with salvage IMRT (S-IMRT). METHODS AND MATERIALS One hundred forty-four patients with high-risk disease at prostatectomy were referred for A-IMRT, and 134 patients with high-risk disease were referred at biochemical recurrence (rising prostate-specific antigen [PSA], following prostatectomy, above 0.2 ng/ml) for S-IMRT. Patients were matched in a 1:1 ratio according to preoperative PSA level, Gleason score, and pT stage. Median doses of 74 Gy and 76 Gy were prescribed for A-IMRT and S-IMRT, respectively. We report biochemical relapse free survival (bRFS) rates using the Kaplan-Meier method. Univariate and multivariate analyses were used to examine tumour- and treatment-related factors. RESULTS A total of 178 patients were matched (89:89). From the end of radiotherapy, the median follow-up was 36 months for both groups. The 3-year bRFS rate for the A-IMRT group was 90% compared to 65% for the S-IMRT group (p < 0.05). On multivariate analysis, S-IMRT, Gleason grades of ≥ 4+3, perineural invasion, preoperative PSA level of ≥ 10 ng/ml, and omission of androgen deprivation (AD) were independent predictors for a reduced bRFS (p < 0.05). From the date of surgery, the median follow-up was 43 and 60 months for A-IMRT and S-IMRT, respectively. The 3-year bRFS rate for A-IMRT was 91% compared to 79% for S-IMRT (p < 0.05). On multivariate analysis, Gleason grades of ≥ 4+3, perineural invasion, and omission of AD were independent predictors for a reduced bRFS (p < 0.05). S-IMRT was no longer an independent prognostic factor (p = 0.08). CONCLUSIONS High-dose A-IMRT significantly improves 3-year bRFS compared to S-IMRT. Gleason grades of ≥ 4+3, perineural invasion, and omission of AD were independent prognostic factors for a decreased bRFS, both from the dates of surgery and from radiotherapy.

High-Dose Salvage Intensity-Modulated Radiotherapy With or Without Androgen Deprivation After Radical Prostatectomy for Rising or Persisting Prostate-Specific Antigen: 5-Year Results

BACKGROUND Long-term results with salvage radiotherapy (SRT) for a biochemical recurrence after radical prostatectomy (RP) are poor. It has been suggested that radiotherapy doses >70 Gy might result in improved outcome. OBJECTIVE To report on the late toxicity profile and outcome of patients treated with high-dose salvage intensity-modulated radiotherapy (HD-SIMRT) with or without androgen deprivation (AD). DESIGN, SETTING, AND PARTICIPANTS Between 1999 and 2008, 136 patients were referred for HD-SIMRT with or without AD. The median follow-up was 5 yr. Indications for HD-SIMRT were persisting prostate-specific antigen (PSA) or a rising PSA following RP. All patients were irradiated at a single, tertiary, academic centre. AD was initiated on the basis of seminal vesicle invasion, preprostatectomy PSA >20 ng/ml, Gleason score ≥ 4+3 (n=43), or personal preference of the referring urologist (n=54). INTERVENTION A median 76-Gy dose was prescribed to the RP bed using intensity-modulated radiotherapy (IMRT) in all patients. AD consisted of a luteinising hormone-releasing hormone analogue for 6 mo. MEASUREMENTS Univariate and multivariate analyses were used to examine the influence of patient- and treatment-related factors on late toxicity, biochemical relapse-free survival (bRFS), and clinical relapse-free survival (cRFS). RESULTS AND LIMITATIONS The 5-yr actuarial bRFS and cRFS were 56% and 86%, respectively. On multivariate analysis, the presence of perineural invasion at RP (hazard ratio [HR]: 6.19, p=0.001) and an increasing pre-SRT PSA (PSA 0.5 ng/ml: HR: 1; PSA 1-1.5 ng/ml: HR: 1.60, p=0.30; and PSA >1 ng/ml: HR: 2.70, p=0.02) were independent factors for a decreased bRFS. The addition of AD improved bRFS (HR: 0.33, p=0.005). On multivariate analysis, none of the variables was a predictor of cRFS. The 5-yr risk of grade 2-3 toxicity was 22% and 8% for genitourinary and gastrointestinal symptoms, respectively. CONCLUSIONS IMRT allows for safe dose escalation to 76Gy with good bRFS.

Perineal Anastomotic Urethroplasty for Posttraumatic Urethral Stricture With or Without Previous Urethral Manipulations: A Review of 61 Cases With Long-Term Followup

PURPOSE We retrospectively analyzed cases of anastomotic urethroplasty for posttraumatic urethral strictures that were done at our center. Surgical and functional outcomes were evaluated. The impact of previous urethral manipulations was assessed. MATERIAL AND METHODS Between 1993 and 2006, 61 males were treated with anastomotic urethroplasty because of urethral trauma after pelvic fracture. Mean followup was 67 months (range 19 to 173). In 21 of the 61 cases (34.4%) urethral manipulation had been performed previously (secondary cases) but had failed. All patients were treated via the perineal approach. RESULTS In 9 patients (14.8%) recurrence was reported. The recurrence rate was higher in patients who underwent former treatment than in primary patients (19% vs 12.5%). Posttraumatic impotence was reported by 20 patients (32.8%) but in 2 erectile function was restored after treatment. One patient had minor stress incontinence. In 2 secondary cases the rectum was injured during the procedure but could be repaired. CONCLUSIONS Anastomotic urethroplasty via the perineal approach is an excellent treatment for posttraumatic urethral stricture. Results are good at long-term followup. Although statistical significance has not been attained, failures and complications seem to be higher in patients who have already undergone failed urethroplasty.

Population screening for prostate cancer: An overview of available studies and meta‐analysis

The objective of the present review was to evaluate the effect of population‐based screening on the incidence of prostate cancer, prostate cancer tumor stage and grade, prostate cancer mortality, and overall mortality. A systematic review was carried out in April 2011, searching the Medline and Web of Science databases. The records were reviewed to identify comparative and randomized controlled trials evaluating the effect of screening on prostate cancer. Eight trials were identified containing personalized data on a screened versus a non‐screened cohort. Prostate‐specific antigen and digital rectal examination were the main screening tools. Prostate‐specific antigen threshold and screening interval was not uniform among the different trials. Screening was associated with a significant increase in prostate cancer detection (relative risk 1.55; P = 0.002), and a significant shift towards more localized (relative risk 1.81; P = 0.01) and more low‐grade tumors (relative risk 2.32; P = 0.001). In overall analysis, no significant effect on prostate cancer mortality (relative risk 0.88; P = 0.18) and overall mortality (relative risk 0.90; P = 0.27) in favor of screening was observed. An adjusted analysis excluding papers with short follow up, high prostate‐specific antigen contamination in the non‐screening group and low participation in the screening group was able to show a significant reduction in prostate cancer mortality of 24%. The ideal screening strategy is unclear. Screening is associated with better PC detection and this in a more localized stage and of less aggressive tumors. Excluding the main shortcomings in screening studies (short follow up, high prostate‐specific antigen contamination in non‐screening group and low participation in screening group), screening is able to reduce prostate cancer mortality.

The AdVance male sling as a minimally invasive treatment for intrinsic sphincter deficiency in patients with neurogenic bladder sphincter dysfunction: A pilot study†‡

The aim of the study was to evaluate feasibility, efficacy, and safety of the AdVance male sling in neuropathic male patients with intrinsic sphincter deficiency.

Safe introduction of robot-assisted radical prostatectomy after a training program in a high-volume robotic centre

Introduction: Localized prostate cancer is increasingly treated by robot-assisted radical prostatectomy (RARP). We evaluated the introduction of RARP following a training program at a high-volume robotic center. Materials and Methods: Before starting RARP, a young urologist followed a 6-month training program. The outcome of his first 50 RARPs was compared with the last 50 open radical prostatectomies (ORPs) performed by an experienced urologist at the same institution. Tumor characteristics were similar in both groups. Median follow-up was 12 (RARP) and 31 (ORP) months (p < 0.001). Results: RARP was associated with more nerve sparing (82 vs. ORP 46%, p < 0.001), longer operation time [median 205 (range 120-310) vs. ORP 180 (85-280) min, p = 0.001], lower decline of postoperative hemoglobin [RARP -2.1 (0.1-4.5) vs. ORP -4.0 (1.0-7.0) g/dl, p < 0.001] and shorter catheter stay [6 (5-47) vs. ORP 14 (9-43) days, p < 0.001]. Complication rates were similar. Overall and pT2-positive surgical margin rate was 8 vs. 24% (p = 0.054) and 0 vs. 11.8% (p = 0.114) for RARP vs. ORP, respectively. One-year urinary continence rate was 76.7 (RARP) and 75.8% (ORP, p = 0.833). Conclusions: RARP was safely introduced after a training program in a high-volume robotic center, both surgically, oncologically and functionally.

A comparative study between continent diversion and bladder neck closure versus continent diversion and bladder neck reconstruction in children

OBJECTIVE To assess the long-term outcome of continent diversion in children with structural or neurogenic cause of incontinence, with special interest in differences between closed and open bladder neck procedures. PATIENTS AND METHODS A cohort of 63 children with intractable incontinence treated with continent diversion between January 1998 and January 2008 were reviewed for underlying disease, type of surgery, complications and outcome. RESULTS Forty patients had a continent diversion with open bladder neck (group 1) and 23 patients had their bladder neck closed (group 2: 11 primarily closed; 12 secondarily closed). There was no difference between the two groups in terms of patient characteristics, surgical re-interventions and stone formation. The continence rate however was significantly better in group 2 (95.6% vs 77.5%). CONCLUSION Bladder neck closure with continent diversion as primary or salvage procedure in children with intractable incontinence does not result in extra morbidity and has a high success rate. Thorough urodynamic evaluation of bladder function is the key to success in therapy planning for these children, to minimize the need for re-intervention.

Clean Intermittent Self-Catheterization as a Treatment Modality for Urinary Retention: Perceptions of Urologists

Purpose Clean intermittent self-catheterization (CISC) is now considered the gold standard for the management of urinary retention. In the literature, several articles on patients’ perspectives on CISC and adherence to this technique have been published. No studies have yet explored the points of view of professional caregivers, such as nurses and doctors. The aim of this study was to explore the opinions of urologists about CISC and to evaluate the need for dedicated nurses specialized in CISC through a self-administered questionnaire. Methods A questionnaire was developed to explore the opinions of professional caregivers about self-catheterization and to evaluate the need to provide nurses with specialized education in CISC. Questionnaires were sent to 244 urologists through email. We received 101 completed questionnaires. The response rate was 41.4%. Results Hand function, the presence or absence of tremor, and visual acuity were rated as the most important determinants for proposing CISC to a patient. Twenty-five percent of the urologists reported that financial remuneration would give them a greater incentive to propose CISC. The lack of dedicated nurses was reported by half of the urologists as a factor preventing them from proposing CISC. A meaningful number of urologists thought that patients perceive CISC as invasive and unpleasant. Although most urologists would choose CISC as a treatment option for themselves, almost 1 urologist out of 5 would prefer a permanent catheter. Conclusions This questionnaire gave valuable insights into urologists’ perceptions of CISC, and could serve as the basis for a subsequent broader international study. Further research should also focus on the opinions of nurses and other caregivers involved in incontinence management. Apart from financial remuneration, it is also clear that ensuring sufficient expertise and time for high-quality CISC care is important. This could be a potential role for dedicated nurses.

Evaluating the Current Place of Radiotherapy as Treatment Option for Patients With Muscle Invasive Bladder Cancer in Belgium

Introduction: There is a gap between optimal and actual use of radiotherapy (RT) in muscle‐invasive bladder cancer (MIBC). We investigated the opinions of radiation‐oncologists, urologists, and medical oncologists on use of RT in different cases. Barriers and facilitators for applying guidelines were examined. Material and Methods: A web‐based survey was developed at Ghent University Hospital and conducted from November 18, 2016 to July 17, 2017. The place of primary, adjuvant, and palliative RT was evaluated. Additional questions assessed the use of guidelines, barriers, and facilitators. Results: In total, 126 physicians (57 radiation oncologists, 41 urologists, and 28 medical oncologists) completed the survey. Significant differences in use of RT in the primary and adjuvant setting were observed between radiation oncologists and urologists. Younger age and presence of hydronephrosis are perceived as contraindications for RT in the primary setting. In the adjuvant setting, RT was mainly considered in case of positive surgical margins. All radiation oncologists and 96% of medical oncologists considered palliative RT for patients with painful bone metastases, whereas 21% of urologists did not (P < .001). Clinical decisions are mainly based on EAU guidelines. The most important reason for nonadherence to guidelines is external barriers (18%). One strategy to improve awareness of guidelines is a summary of guidelines on the website of national organizations (54%). Conclusion: There is controversy regarding the place of RT in MIBC, with a clear variation between professionals. Barriers and facilitators to use RT should be addressed, seeing the gap in RT utilization and predicted increase in patients requiring RT for MIBC.