Editorial Comment

Byline: Chad R. Ritch Author Affiliation: Vanderbilt University Medical Center, Nashville, TennesseeAcademi

Photodynamic therapy for low risk prostate cancer

No substitute for active surveillance ye

Urinary biomarkers in bladder cancer: where do we stand?

To provide a current comprehensive review of the available urinary biomarkers for the detection and surveillance of bladder cancer. The limitations of urine cytology and invasive nature of cystoscopic evaluation have led to a growing search for an ideal, cost-effective biomarker with acceptable sensitivity and specificity. Current FDA approved biomarkers such as UroVysion fluorescent in situ hybridization, Immunocyt, and nuclear matrix protein 22 do not have the specificity, and thus positive predictive value to warrant their cost as a routine adjunct or replacement for cystoscopy. Several promising commercially available assays such as Cxbladder, Assure MDx, and Xpert BC may perform better than cytology in select populations. Novel genomic, epigenetic, inflammatory, and metabolomic-based assays are being analyzed as potential urinary biomarkers. Urinary biomarkers with high sensitivity and specificity are an unmet need in bladder cancer. Several new assays may meet these criteria and future research may justify use in clinical practice

Port Placement in Robotic Urologic Surgery

In 2001, the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was approved for use in urology (www.fda.gov) and the technological improvements have translated to a paradigm shift, especially in the field of urologic oncology. Robotic-assisted laparoscopic prostatectomy (RALP) has quickly become the minimally invasive surgical procedure of choice at most centers of excellence and robotic-assisted laparoscopic radical and partial nephrectomy (RALPN/RALN) and cystectomy (RALC) are also increasing in numbers. The impetus for the robotic approach to surgical management is based on a combined need for minimally invasive treatment with optimal surgical outcomes. Historically, conventional laparoscopy has been at the forefront of minimally invasive surgical technique and the fundamental principles of robotic surgery are founded upon those used in laparoscopic surgery. However, the advanced technology utilized in robotics has required modifications of these techniques to capitalize on the enhanced capabilities of robotic surgery. Whereas laparoscopic surgery is limited by counterintuitive movement, 2D visualization, and a decreased range of motion, robotic surgery offers 3D visualization, seven degrees of freedom, and is a natural reflection of the surgeon’s movement. Robotic surgery therefore offers enhanced capabilities for visualization, surgical dexterity, and exposure to the surgical field but these are ultimately dependent on the proper placement of the ports used for access. This chapter will provide a comprehensive overview of the standard techniques for access and port placement in a number of major robotic urologic procedures focusing on the nuances of prostate, renal, bladder, and female robotic urologic surgery

Prostate cryotherapy: current status

Minimally invasive options to treat low-risk prostate cancer are more desirable than radical therapy. Technological improvements in cryotherapy have increased its use, and long-term data on its efficacy are emerging. In this review, we discuss contemporary data on cryotherapy with specific focus on studies using the newest technology. With respect to biochemical recurrence rates, cryotherapy appears to be as effective for low-risk prostate cancer as other treatment modalities. The definition of recurrence remains problematic, though contemporary studies are more consistently using both the American Society for Therapeutic Radiation Oncology and Phoenix criteria. Erectile dysfunction rates are universally high after whole-gland cryoablation, but incontinence and urethrorectal fistula rates appear to be low with third-generation cryo systems. Focal cryotherapy has encouraging short-term efficacy in terms of biochemical disease-free survival rate for unifocal disease, and rates of erectile dysfunction are dramatically lower than those seen with whole-gland cryoablation. Cryosurgery has a promising role in primary and salvage treatment of select prostate cancer patients. Focal cryotherapy for unilateral disease offers the added benefit of minimal adverse effects. Long-term data are emerging to support cryosurgery, and large multicenter databases have been developed to answer questions regarding optimal treatment outcomes and patterns

Advances in the management of castration resistant prostate cancer

Docetaxel based chemotherapy showed survival benefit and emerged as the mainstay of treatment for castration resistant prostate cancer (CRPC) in 2004. However, therapeutic options have expanded rapidly since 2011. The spectrum of new agents is broad and includes drugs that target the androgen axis (enzalutamide, abiraterone), immunotherapy (sipuleucel-T), bone seeking radionuclides (radium-223), and second line chemotherapy (cabazitaxel). In addition, new agents have been developed to reduce skeletal related events (denosumab). Given that docetaxel was the standard first line treatment for metastatic CRPC, the newer oral agents that affect the androgen axis were initially approved in the post-docetaxel setting. However, subsequent randomized trials have led to their approval in the pre-chemotherapy setting as well. Patients with CRPC are clinically heterogeneous, ranging from patients who are asymptomatic and do not have metastases to those with substantial symptoms and both bony and visceral metastases. CRPC is a clinically challenging disease entity, therefore, with a wide array of treatment options and multiple possible sequencing combinations depending on the individual patient. This review will summarize the findings of the randomized trials that led to the approval of the therapies for CRPC. It will also discuss recent guidelines and provide suggestions for sequencing of drugs based on the best available evidence

Clinical Scenario: Large Volume, Non-metastatic T2 Bladder Tumor

The optimal treatment of bulky, non-metastatic, and locally advanced muscle-invasive bladder cancer (MIBC) involves a combination of chemotherapy and radical cystectomy. Evidence exists to support the use of neoadjuvant chemotherapy in the treatment of MIBC; however, there are a number of scenarios where this approach is not feasible or may not be practical. The goal of this chapter is to describe our approach to the treatment of MIBC, in particular the timing and use of chemotherapy with radical cystectomy, and to provide a practical guide based on our clinical experience

Fluoxetine response in children with autistic spectrum disorders: correlation with familial major affective disorder and intellectual achievement

One hundred and twenty-nine children, 2 to 8 years old, with idiopathic autistic spectrum disorder diagnosed by standard instruments (Childhood Austim Ratings Scale and Autism Diagnostic Observation Schedule) were treated with fluoxetine (0.15 to 0.5mg/kg) for 5 to 76 months (mean 32 to 36 months), with discontinuation trials. Response criteria are described. Family histories were obtained using the family history method in repeated interviews. Fluoxetine response, family history of major affective disorder, and unusual intellectual achievement, pretreatment language, and hyperlexia were used to define a coherent subgroup of autistic spectrum disorder. Statistical analyses were post hoc. Of the children, 22 (17%) had an excellent response, 67 (52%) good, and 40 (31%) fair/poor. Treatment age did not correlate with response. Fluoxetine response correlated robustly with familial major affective disorder and unusual intellectual achievement, and with hyperlexia in the child. Family history of bipolar disorder and of unusual intellectual achievement correlated strongly. Five children developed bipolar disorder during follow-up. Fluoxetine response, family history of major affective disorder (especially bipolar), unusual achievement, and hyperlexia in the children appear to define a homogeneous autistic subgroup. Bipolar disorder, unusual intellectual achievement, and autistic spectrum disorders cluster strongly in families and may share genetic determinants

Restaging Transurethral Resection for Non-Muscle Invasive Bladder Cancer

The rate of clinical understaging in non-muscle invasive bladder cancer (NMIBC) after an initial transurethral resection (TUR) is significant, particularly for high-grade disease, and this has a major impact on prognosis. A repeat TUR, 2 to 6 weeks following the initial resection, is recommended in appropriately selected cases to avoid diagnostic inaccuracy and improve treatment allocation. This article summarizes the rationale and indications for performing a repeat TUR in NMIBC and also provides information regarding patient selection and technique