Avelumab maintenance therapy for node-positive muscle invasive bladder cancer: a report of two cases.

Background: Muscle-invasive bladder cancer (MIBC) with nodal involvement is associated with poor prognosis and high mortality. Treatment of node-positive MIBC is complex due to disease heterogeneity and a lack of evidence-based treatment options, especially alternatives to radical cystectomy. We describe a bladder-sparing management approach involving systemic therapy followed by maintenance therapy, illustrated with two cases of node-positive MIBC. Case presentation: Two patients with node-positive MIBC received upfront gemcitabine/cisplatin chemotherapy, concurrent chemoradiotherapy (cCRT), and avelumab (immune checkpoint inhibitor) maintenance therapy. Both patients achieved complete remission without recurrence or distant metastasis post-avelumab maintenance therapy. At the last follow-up, Patient 1 (45-year-old male) was in remission for over two years, and Patient 2 (57-year-old male) was in complete remission for over one year post-chemotherapy. Avelumab treatment was well-tolerated, with no immune-related adverse events, and quality of life (QoL) was maintained. Conclusion: Both cases showed a good response and extended remission on avelumab maintenance, supporting its use in conjunction with local consolidation therapy as a bladder-preserving approach in node-positive MIBC. Further research, such as the ongoing INSPIRE trial, is required to refine treatment strategies for this patient group.

Asian guidelines for UTIs & STIs UTI section: Complicated UTIs with neurogenic bladder.

EPIDEMIOLOGY AND PATHOGENESIS: Urinary tract infection (UTI) in patients with neurogenic bladder causes significant morbidity and mortality. DIAGNOSIS: UTI in neurogenic bladder causes atypical symptomatology. Urine tests are pivotal in confirming or excluding UTI, and in guiding appropriate antibiotic treatment. TREATMENT: 1. Symptomatic UTI warrants appropriate antibiotic treatment with reference to culture results and local antibiotic resistance patterns. Asymptomatic bacteriuria should not be treated, and antibiotic prophylaxis is generally not recommended.2. Adequate bladder drainage is essential in reducing the occurrence of urinary tract infections.3. Recurrent UTI in neurogenic bladder may necessitate the treatment of neurogenic detrusor overactivity and the restoration of low bladder pressure during bladder storage and voiding by drugs or surgery.

Prostate cancer management in the era of COVID-19: Recommendations from the Hong Kong Urological Association and Hong Kong Society of Uro-oncology.

AIM: In response to the fast-developing coronavirus disease 2019 (COVID-19) pandemic, special arrangement and coordination are urgently required in the interdisciplinary care of patients across different medical specialties. This article provides recommendations on the management of different stages of localized or metastatic prostate cancer (PC) amid this pandemic. METHODS: The Hong Kong Urological Association and Hong Kong Society of Uro-oncology formed a joint discussion panel, which consisted of six urologists and six clinical oncologists with extensive experience in the public and private sectors. Following an evidence-based approach, the latest relevant publications were searched and reviewed, before proceeding to a structured discussion of relevant clinical issues. RESULTS: The joint panel provided recommendations for PC management during the pandemic, in terms of general considerations, diagnostic procedures, different disease stages, treatment modules, patient support, and interdisciplinary collaboration. The overall goal was to minimize the risk of infection while avoiding unnecessary delays and compromises in management outcomes. Practical issues during the pandemic were addressed such as the use of invasive diagnostic procedures, robotic-assisted laparoscopic prostatectomy, hypofractionated radiotherapy, and prolonged androgen deprivation therapy. The recommendations were explicated in the context of Hong Kong, a highly populated international city, in relation to the latest international guidelines and evidence. CONCLUSION: A range of recommendations on the management of PC patients during the COVID-19 pandemic was developed. Urologists, oncologists, and physicians treating PC patients may refer to them as practical guidance.

Hong Kong Urological Association-Hong Kong Society of Uro-Oncology consensus statements on the management of advanced prostate cancer-2019 Updates.

BACKGROUND: To update the Hong Kong Urological Association-Hong Kong Society of Uro-Oncology consensus statements on the management of advanced prostate cancer, the same panelists as in the previous consensus panel held a series of meetings to discuss updated clinical evidence and experiences. METHODS: The previous consensus statements were retained, deleted, or revised, and new statements were added. At the final meeting, all statements were reviewed and amended as appropriate, followed by panel voting. RESULTS: There were significant changes and additions to the previous consensus statements, primarily driven by the advances in androgen receptor signaling inhibitors, treatment sequencing in metastatic castration-resistant prostate cancer, and increasing recognition of oligometastatic prostate cancer since the introduction of prostate-specific membrane antigen positron emission tomography. In this update, a total of 59 consensus statements were accepted and established. CONCLUSIONS: The consensus panel updated consensus statements on the management of advanced prostate cancer, aiming to allow physicians in the region to keep abreast of the recent evidence on optimal clinical practices.

Management of advanced prostate cancer in Hong Kong: Insights from an APCCC-Derived survey.

AIM: The 2017 Advanced Prostate Cancer Consensus Conference (APCCC) convened an international multidisciplinary panel to vote on controversial issues in the management of advanced prostate cancer (APC). We aimed to compare their conclusions with the opinions of local specialists and explore the practicability of international recommendations in the healthcare setting in Hong Kong. METHODS: Urologists and clinical oncologists practicing in Hong Kong were invited to complete a survey based on the original APCCC 2017 questionnaire and recently published trials in APC. A joint committee of expert key opinion leaders was convened to discuss and analyze the voting differences between local specialists and the APCCC 2017 panel. RESULTS: The respondents constituted 21% (28/132) of registered urologists and 21% (31/146) of clinical oncologists in Hong Kong. Discrepancies in three key areas were identified as being the most timely for this analysis: (a) management of metastatic hormone-sensitive/naïve prostate cancer; (b) management of metastatic castration-resistant prostate cancer; and (c) treatment monitoring and initiation of androgen-deprivation therapy. Fears of toxicity and intolerance among patients and physicians (especially urologists) may be driving the relative underuse of chemotherapy in multiple APC patient groups in Hong Kong. Local patients can face long wait times and limited access to contemporary imaging modalities compared with other developed countries. CONCLUSION: Increased collaborative efforts by urologists and clinical oncologists could ensure that patients gain wider access to the latest diagnostic, treatment and monitoring modalities for APC in Hong Kong.

Consensus statements on the management of clinically localized prostate cancer from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology.

OBJECTIVE: To formulate consensus statements to facilitate physician management strategies for patients with clinically localized prostate cancer (PCa) in Hong Kong by jointly convening a panel of 12 experts from the two local professional organizations representing PCa specialists, who had previously established consensus statements on the management of metastatic PCa for the locality. METHODS: Through a series of meetings, the panellists discussed their clinical experience and the published evidence regarding various areas of the management of localized PCa, then drafted consensus statements. At the final meeting, each drafted statement was voted on by every panellist based on its practicability of recommendation in the locality. RESULTS: A total of 76 consensus statements were ultimately accepted and established by panel voting. CONCLUSION: Derived from the recent evidence and major overseas guidelines, along with local clinical experience and practicability, the consensus statements were aimed to serve as a practical reference for physicians in Hong Kong for the management of localized PCa.

Symptom prevalence, bother, and treatment satisfaction in men with lower urinary tract symptoms in Southeast Asia: a multinational, cross-sectional survey.

PURPOSE: The overall objective of the survey was to systematically examine patients' perspectives on lower urinary tract symptoms (LUTS) and their treatment in Southeast Asia. METHODS: A multinational cross-sectional survey involving adult men seeking consultation at urology outpatient clinics because of LUTS in Southeast Asia was conducted using convenience sampling. Self-reported prevalence, bother, treatment and treatment satisfaction of selected LUTS including urgency, nocturia, slow stream, and post-micturition dribble were evaluated. RESULTS: In total, 1535 eligible patients were enrolled in the survey. A majority of respondents were aged 56-75 years, not employed, and had not undergone prostate operation before. Overall, the self-reported prevalence of nocturia was 88% (95% CI 86-90%), slow stream 61% (95% CI 59-63%), post micturition dribble 55% (95% CI 52-58%), and urgency 52% (95% CI 49-55%). There were marked differences in the country specific prevalence of LUTS complaints. Frequently, symptoms coexisted and were combined with nocturia. More than half of patients felt at least some degree of bother from their symptoms: 61% for urgency, 57% for nocturia, 58% for slow stream, and 60% for post-micturition dribble. Before seeing the present urologists, nearly half of patients have received some form of prescribed treatment and more than 80% of patients indicated they would like to receive treatment. CONCLUSION: Men who sought urologist care for LUTS often presented with multiple symptoms. Nocturia emerged as the most common symptom amongst the four core symptoms studied.

Consensus statements on the management of metastatic prostate cancer from the Hong Kong Urological Association and Hong Kong Society of Uro-Oncology.

To establish a set of consensus statements to facilitate physician management strategies for patients with metastatic prostate cancer (mPCa) in Hong Kong. A local expert consensus was organized jointly by the two main professional organizations representing prostate cancer specialists in Hong Kong. A total of 12 experts were included in the consensus panel. Six of the most crucial and relevant areas of debate regarding the management of mPCa were identified. With the use of a modified Delphi method, several panel meetings were held for the members to discuss their clinical experience and the published literature relevant to the areas of debate. At the final meeting, each drafted statement was voted on by every member based on its practicability of recommendation in the locality. After the panel voting, a total of 45 consensus statements regarding the management of mPCa were ultimately accepted and established. The consensus statements were primarily derived from the latest clinical evidence and major overseas guidelines, with the consideration of local clinical experience and practicability. These are considered applicable recommendations for Hong Kong physicians for the management of mPCa patients.

Does classroom-based crew resource management training have an effect on attitudes between doctors and nurses?

OBJECTIVE: To evaluate participant reactions and attitudes to crew resource management teamwork classroom-based training by comparing Likert responses before and after the intervention and exploring potential differences in attitudes across the different healthcare professionals. METHODS: Between 26 January and 27 March, 2015, a randomly selected sample of 240 frontline healthcare professionals offering direct patient care were recruited to undergo a 4-hour crew resource management classroom-based training programme. Participants were asked to complete a 22-item human factors attitude survey before and after training and a 10-item end-of-programme evaluation. Paired samples t-test was used to assess differences between the participants' pretest and posttest scores on each item. RESULTS: A total of 167 (70%) from 17 different specialties underwent the training and 164 (68.3%) completed (139 nurses, 25 doctors) the survey. The nurses were of similar age to the doctors (38.2 vs 36.9, p=0.83) and were more likely to be women (75.6% vs 24.6%, p <0.001). Human factors attitude survey findings indicated that nurses valued the experience highly compared to doctors. The responses among the nurses revealed significant attitude shifts (p <0.05) in 20 of the 22 items whereas this was the case only for 9 items among the doctors. CONCLUSIONS: Overall, the crew resource management classroom-based training programme appeared to have a positive effect on frontline healthcare professionals' attitudes. The implementation of such programme is feasible and acceptable, especially for nurses, in a public hospital setting in Hong Kong.

Augmentation cystoplasty: Urodynamic and metabolic outcomes at 10-year follow-up.

OBJECTIVE: To review the urodynamic outcomes, renal function and metabolic complications after augmentation cystoplasty with at least 10 years of follow-up. METHODS: Augmentation cystoplasty performed in two tertiary referral centers from 1995 to 2004 were reviewed. Ten years or more postoperative course was studied by review of the clinical notes, urodynamic reports and laboratory results. RESULTS: A total of 40 patients were included in this study. The mean age at surgery was 43 years, and 47.5% of patients were female. Median follow up was 13 years. Bladder capacity significantly increased from 283 ± 151 to 492 ± 123 mL (P < 0.01), with a percentage change of +130%. The compliance of the bladder was increased by 87%, and detrusor overactivity decreased by 54.2%. There were no significant changes in preoperative and postoperative estimated glomerular filtration rate (68.3 mL/min vs. 76.6 mL/min, P = 0.798). Three patients (7.5%) had more than one episode of symptomatic urinary tract infection per year. CONCLUSION: The present study confirms the effectiveness of augmentation cystoplasty in increasing bladder capacity, improving bladder compliance and reducing detrusor overactivity. The preservation of renal function and low metabolic complication rate provide solid evidence for carrying out this time-honored procedure in patients with neurogenic or non-neurogenic bladder dysfunction.

Heat Damage Zones Created by Different Energy Sources Used in the Treatment of Benign Prostatic Hyperplasia in a Pig Liver Model.

INTRODUCTION: There are different types of transurethral prostatic surgeries and the complication profiles are different. This study aims to compare the heat damage zones (HDZ) created by five different technologies in a pig liver model. MATERIALS AND METHODS: Monopolar resection, bipolar resection, electrovaporization, and Greenlight™ lasers of 120 and 180 W were used to remove fresh pig liver tissue in a simulated model. Each procedure was repeated in five specimens. Two blocks were selected from each specimen to measure the three deepest HDZ. RESULTS: The mean of HDZ was 295, 234, 192, 673, and 567 µm, respectively, for monopolar resection, bipolar resection, electrovaporization, Greenlight laser 120 W, and Greenlight laser 180 W, respectively. The Greenlight laser produced one to three times deeper HDZ than the other energy sources (p=0.000). CONCLUSION: Both 120 and 180 W Greenlight lasers produced deeper HDZ than the other energy sources. Urologists need to be aware of HDZ that cause tissue damage outside the operative field.

Pre-operative tumor localization and evaluation of extra-capsular extension of prostate cancer: how misleading can it be?

PURPOSE: To verify the accuracy of transrectal ultrasound-guided prostatic biopsy (TRUS Bx), magnetic resonance imaging (MRI) and their combination in evaluating the laterality of prostate cancer and to determine the accuracy of MRI in assessing extra-capsular extension of prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed our past 100 consecutive series of radical prostatectomy performed between February 2010 and April 2012 at our institution. Their TRUS Bx and MRI results were compared with the pathology of the radical prostatectomy specimens. For tumor localization, we calculated the accuracies in unilateral diseases, bilateral diseases, overall accuracies and Cohen Kappa concordance coefficient of TRUS Bx, MRI and their combination. For the assessment of extra-capsular extension, we calculated the sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, likelihood ratio positive and likelihood ratio negative of MRI. RESULTS: Eighty-two percent of our radical prostatectomy specimens had bilateral tumor involvement and 32% had extra-capsular extension. The accuracies of TRUS Bx in unilateral disease, bilateral disease and overall accuracy were 15.2%, 91.4% and 43.6%, respectively. The accuracies of MRI in unilateral disease, bilateral disease and overall accuracy were 11.1%, 66.7% and 38.9%, respectively. When combining the assessment of TRUS Bx and MRI, the accuracies in unilateral disease, bilateral disease and overall accuracy were 16.7%, 75% and 55.6%, respectively. The Cohen Kappa concordance co-efficient of TRUS Bx, MRI, and combination of them were 0.1165, -0.2047 and -0.1084, respectively. The positive predictive value, negative predictive value, sensitivity, specificity, overall accuracy, likelihood ratio positive and likelihood ratio negative of MRI in assessing extra-capsular extension were 33.3%, 69.8%, 5.9%, 94.9%, 67.9%, 1.16 and 0.99, respectively. CONCLUSION: TRUS Bx, MRI, and their combination had poor concordance and limited accuracies in assessment of the laterality of tumor involvement. The combination of TRUS Bx and MRI offered a better of accuracy when compared to either modality alone. MRI was a specific, but not sensitive tool in assessing the presence of extra-capsular extension.

The effect of urethral calibration on female primary bladder outlet obstruction.

INTRODUCTION AND HYPOTHESIS: While primary bladder outlet obstruction (BOO) in women has become an increasingly recognized entity over the past few years, the optimal management for such condition is yet to be defined. We assessed the effect of urethral calibration in the treatment of female BOO. METHODS: A retrospective review of female patients undergoing urethral calibration with urethral dilator for BOO from 2000 to 2009 was performed. BOO was defined as a maximum flow rate (Qmax) of less than 15 ml/s together with a detrusor pressure at maximum flow rate (PdetQmax) of more than 20 cmH(2)O in urodynamic studies in the absence of neurological disorders or mechanical causes. Pre-calibration and post-calibration urodynamic studies were compared. RESULTS: Twenty women were diagnosed of BOO on urodynamic criteria (mean age 56 ± 14 years). Sixty percent of the patients had obstructive symptoms, while 50% of them had irritative symptoms. Reassessment urodynamic studies were performed 6 months after urethral calibration. Although there was no significant change in Qmax and post-void residual urine after urethral calibration (9.6 ± 2.8 vs 9.7 ± 4.0 ml/s, p = 0.869 and 246 ± 196 vs 263 ± 198 ml, p = 0.753, respectively), PdetQmax significantly improved (72.2 ± 39 vs 50.2 ± 30.5 cmH(2)O, p = 0.013). Only one patient developed urinary tract infection after the procedure. No complication of incontinence had been observed. Among the 20 patients, 13 patients (65%) had a second urethral calibration after the reassessment urodynamic study for persistent symptoms. CONCLUSIONS: Female patients with bladder outlet obstruction showed improvement in the urodynamic parameters after urethral calibration. However, its durability is not certain yet. Future studies concerning clinical symptoms correlation with urodynamic parameters would help further delineate the role of urethral calibration in the management of bladder outlet obstruction in women.