Of particular concern, the researchers noted, is that patients with pre-existing chronic kidney disease (CKD) had a nearly twofold increased likelihood of undergoing RN than NSM compared with patients without CKD. Even though NSM use increased over the study period, most CKD patients still received RN, the investigators found.

via Nephron-Sparing Treatments Underused in CKD Patients – Renal and Urology News.

This study looked at data from the 1998-2008 and found that most renal masses were being treated by removing the entire kidney, even in patients with kidney disease.  I have been performing partial nephrectomies for renal masses that were less than 4cm since I was at Indiana in 1997.  Over the last 5 years, I have performing partial nephrectomies for tumors as large as 9cm if the location would allow it.

The AUA’s list identified the following five recommendations:

A routine bone scan is unnecessary in men with low-risk prostate cancer.

Do not prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

Do not order creatinine or upper tract imaging in men with BPH.

Do not treat an elevated PSA with antibiotics for patients not experiencing other symptoms.

Do not perform ultrasound on boys with cryptorchidism.

via AUA: Five tests, treatments may be unnecessary | Urology Times.

The AUA has made recommendations on several areas.  There were two that were important for men in the area of prostate cancer.

Men with early stage prostate caner do not need a routine bone scan.  During my training at Indiana University from 1997-2003 this was the standard of care in my residency. Historically, all men with prostate cancer had a bone scan and CT scan.  Both of these are not necessary for men with low grade prostate cancer.  I have not ordered routine bone scans since coming to west Orange, NJ in 2003.

The other important recommendation was in the treatment of an elevated PSA with antibiotics.  This is the first time I have seen the AUA make the recommendation.  If men have stable urinary symptoms and no inflammatory (WBC) cells in the urine, antibiotics should not be prescribed.  I have been practicing in this fashion my entire career, but many physicians including urologists would often prescribe antibiotics to see if an elevated PSA  would return to normal values.

The safety of robots made by Intuitive Surgical Inc. (ISRG) is being probed by U.S. regulators, raising questions about the prospects of one of the hottest technologies in health care.

The Food and Drug Administration asked surgeons at key hospitals to list the complications they may have seen with the machines, which cost about $1.5 million each and were used last year in almost 500,000 procedures. The doctors were also surveyed on which surgeries the robots might be most and least suited for, and asked to discuss their training, according to copies of the survey obtained by Bloomberg News.

via Intuitive Robot Probe Threatens Trend-Setting Surgeries – Bloomberg.

Bloomberg has reported that The FDA has inquired into complications resulting during robotic surgery.  I believe this inquiry is targeted towards gynecologic surgery.

I have been involved with robotic surgery for 9 years and have seen many different instruments and different robotic platforms (davinci, davinci S, davinci Si).  There is inherent risk in any surgical procedure, whether surgery is performed robotically, laparoscopically, or with an open incision.  I believe an experienced surgeon and team can  lead to lower complication rates and I do feel that robotic surgery is inherently safer in that it has a lower complication rate in my personal experience at least.

Uchek tests for 25 different health issues and could help diagnose and treat diseases in the developing world.Increasingly mobile health is being talked up as a lifesaver in such areas.The app is the brainchild of TED fellow Myshkin Ingawale.”I wanted to get medical health checks into users hands,” he told the BBC.

via BBC News – TED 2013: Uchek app tests urine for medical issues.

As technological advances are made, how we screen and test for many conditions will be simplified and streamlined.

This article discussed an app for the iPhone that will read a dipstick in an automated manner.  This will need to be tested against current standards, but I am confident in the near future (5 years) there will be testing available in ways that we would not have thought possible 5 years ago.

FDA approves Botox to treat overactive bladder

The U.S. Food and Drug Administration today expanded the approved use of Botox (onabotulinumtoxinA) to treat adults with overactive bladder who cannot use or do not adequately respond to a class of medications known as anticholinergics.

via Press Announcements > FDA approves Botox to treat overactive bladder.

Men and women both can suffer from overactive bladder.  Patients usually are treated with exercises and medications (anticholinergics) to help reduce the overactivity of the bladder.  Symptoms such as frequency of urination, urgency of urination, and leakage of urine from the overactive bladder usually improve.  These medications can cause constipation, dry mouth, and other side effects.  Patients that can not tolerate medications have another option now.  Urologists can inject botox into the bladder and improve urinary symptoms.

Patients that have had prostatectomies sometimes have urge incontinence after prostatectomy and botox should be considered if other options have not worked or have not been tolerated.

The median follow-up for patients still alive at the last follow-up was 8.3 years. The estimated overall survival rates at 10 and 15 years were 69% and 53%, respectively, for RN compared with 80% and 74%, respectively, following PN. Compared with PN-treated patients, patients who underwent RN were 75% more likely to die from any cause and more than four times more likely to develop stage IV chronic kidney disease, after adjusting for covariates, according to findings published online in European Urology. All of these differences between the RN and PN group were significant.

via Partial Nephrectomy Offers Better Renal Preservation, Survival – Renal and Urology News.

There have been several studies that concluded that patients that have kidney tumors and have only part of their kidney removed (partial nephrectomy) vs. the entire kidney removed (total or radical nephrectomy) have less kidney problems in the future.  They patients with nephron sparing surgery (partial) lived longer as well.

Not all patients are candidates for removing only part of the kidney, but most with tumors under 4cm and most with tumors not in the middle of the kidney should have a partial nephrectomy as a consideration.

At Newark Beth Israel, I have been performing robotic partial nephrectomy since 2005.  In 2007 I started using intraoperative renal ultrasound to better show the kidney anatomy.  In 2012 I started using firefly to help me perform more accurate kidney surgery for suspected kidney cancer.

The European Medicines Agencys Committee for Medicinal Products for Human Use CHMP has recommended extending the use of the prostate cancer pill abiraterone acetate Zytiga, Janssen to include men with advanced prostate cancer who fail on androgen-deprivation therapy.The drug is currently approved in Europe and the United States for these same men, but only as second-line treatment, after docetaxel chemotherapy. If approved, abiraterone could be used by European clinicians as a first-line treatment for men who progress on androgen-deprivation therapy.Specifically, CHMP recommended that abiraterone be administered in combination with prednisone for the treatment of patients with metastatic castration-resistant prostate cancer mCRPC who are asymptomatic or mildly symptomatic after the failure of androgen-deprivation therapy.

via Europe Gives Nod to Prostate Cancer Pill Before Chemo.

Abiraterone is a well tolerated oral medication that currently has been FDA approved in the treatment of men with advanced (metastatic castrate resistant prostate cancer {mCRPC}) prostate cancer who have received previous chemotherapy containing docetaxel.  This indication is being sought in the US as well.

Drinking green tea may play a role in the inhibition of prostate cancer tumor growth, according to a study presented at the American Association for Cancer Research’s International Conference on Frontiers in Cancer Prevention Research in Anaheim, Calif.

via Green Tea May Inhibit Prostate Cancer Tumor Growth – Renal and Urology News.

Green tea is one of the drinks that I think is helpful for men with prostate cancer.  This study showed intracellular changes seen in prostate cancer cells in men that were drinking it.

Results:Of the 114 patients who underwent laparoscopic prostatectomy, 64 56% were deemed suitable for removal of catheter on second postoperative day prior to discharge. The first 20 patients selected for early removal of urethral catheter were covered with a suprapubic catheter inserted at the time of surgery. Out of 64 patients deemed suitable for early removal of urethral catheter, 53 83% were able to pass urine without complication. 11 patients 17% developed urinary retention that necessitated recatheterisation. In all cases, reinsertion of catheter was performed easily and successfully without the need for cystoscopic guidance or adjuncts.

via Safe removal of the urethral catheter 2 days following laparoscopic radical prostatectomy – Abstract | Prostate Cancer | UroToday | Urology Information.

This study looked at patients who were deemed suitable to have their catheters removed after 2 days of laparoscopic prostatectomy.  This was not done robotically, which makes the skill of the surgeons in accurate suturing very impressive.  They had a relatively high re-cathetrization rate of 17%.  I wonder if these patients were still in the hospital on day number 2.  Urinary retention is a bigger deal if the patient is at home and has to come to the office or emergency room for catheter reinsertion.

I did not read the paper, just the abstract, but I assume they did not perform any reconstructive techniques that I have been performing since 2007.  This reconstructive work makes the bladder neck more fixed and I have not seen very much retention (2-3%) when I have removed catheters after 2-3 days after dvP.

RESULTS: PCa was detected on biopsy in 192 39.8% patients. PCa was detected only in the TZ for 10 patients 5.2%, only in the PZ for 69 patients 35.9%, and in both the TZ and PZ for 113 patients 58.9%. Obtaining a biopsy only from the TZ resulted in a significantly lower cancer detection rate than obtaining the biopsy only from the PZ or from the combined PZ and TZ P < .05. High GSs ≥ 7 were found in 3 of 10 patients 30% with PCa detected in the TZ, 29 of 69 patients 42% with PCa detected in the PZ, and 90 of 113 patients 79.6% with PCa detected in the combined TZ and PZ. Among the patients with PSA levels < 10 ng/mL, none of the 4 patients with PCa detected only in the TZ had GSs ≥ 7; however, 14 of 41 patients 34.1% with PCa detected only in the PZ and 18 of 32 patients 56.3% with PCa detected in the combined TZ and PZ had GSs ≥ 7. Patients with a biopsy only from the TZ had significantly fewer GSs ≥ 7 than patients with a biopsy only from the PZ or from the combined PZ and TZ in this PSA rangeP < .05.CONCLUSION: It may be possible to omit a prostate biopsy from the TZ for patients with serum PSA < 10 ng/mL.

via Is the transitional zone biopsy specimen significant for prostate cancer detection? – Abstract | Prostate Cancer | UroToday | Urology Information.

A transition zone biopsy is when tissue is taken from the middle part of the prostate.  This part usually has benign elements from BPH and not cancer.  I usually biopsy the transition zone in patients that have had a negative biopsy and need a repeat biopsy for a rising PSA.

From memory, I have seen patients with transition only prostate cancer and have performed robotic prostatectomy on them.  The ones that had a surprising (more than we would expect) amount of prostate cancer were the ones with the PSA over 10.

I will continue to perform the prostate biopsy as I have done after this article, but will think of ways of looking into this more with my practice.  I do not think the morbidity of 2 extra transition zone biopsies is very different than a standard biopsy.  My standard biopsy currently has 12 cores with 2 extra cores from the anterior apex, which has led to a better cancer detection rate and I have used the presence of cancer at the apex to better delineate the amount of tissue I leave on the anterior prostate apex.