OBJECTIVES To investigate the relationship between prostate‐specific antigen (PSA) level and tumour volume for incidental adenocarcinoma of the prostate found in cystoprostatectomy (CP) specimens, and to analyse the incidence of clinically significant prostate cancers in CP specimens and the biochemical recurrence of incidental prostate cancers on short‐term follow up. PATIENTS AND METHODS Complete data from 97 of 105 prostates from CP specimens were available. Prostates were thoroughly analysed and sectioned at 2 mm intervals. PSA levels and the findings at digital rectal examination before surgery were obtained prospectively. None of the patients had any evidence of prostate cancer before CP. RESULTS Incidental prostate cancer was detected in 58 of 97 (60%) of the CP specimens; of these, 31 (53%) were significant according to the definition of Stamey et al. There was a weak correlation between tumour volume and PSA level, weighted solely by the four larger‐volume cancers. The median PSA level for patients with and without prostate cancer was not significantly different (3.1 vs 1.1 ng/mL, P = 0.06). The follow‐up of the 35 patients alive with prostate cancer showed four PSA recurrences (PSA >0.02 ng/mL) with one distant metastasis after a median follow‐up of 3 years. None of the patients with insignificant tumours developed biochemical recurrence. CONCLUSIONS The weak correlation between PSA level and tumour volume in these patients supports the argument that PSA is largely produced by benign prostatic hyperplasia and is therefore a poor screening tool for asymptomatic healthy men. Most incidental prostate cancers in CP specimens are significant, contrary to previous analyses, but have little practical importance in terms of oncological outcome.

ObjectivesTo describe the frequency and nature of symptoms in patients presenting with suspected renal cell carcinoma (RCC) and examine their reliability in achieving early diagnosis.DesignMulticentre prospective observational cohort study.Setting and participantsEleven UK centres recruiting patients presenting with suspected newly diagnosed RCC. Symptoms reported by patients were recorded and reviewed. Comprehensive clinico-pathological and outcome data were also collected.OutcomesType and frequency of reported symptoms, incidental diagnosis rate, metastasis-free survival and cancer-specific survival.ResultsOf 706 patients recruited between 2011 and 2014, 608 patients with a confirmed RCC formed the primary study population. The majority (60%) of patients were diagnosed incidentally. 87% of patients with stage Ia and 36% with stage III or IV disease presented incidentally. Visible haematuria was reported in 23% of patients and was commonly associated with advanced disease (49% had stage III or IV disease). Symptomatic presentation was associated with poorer outcomes, likely reflecting the presence of higher stage disease. Symptom patterns among the 54 patients subsequently found to have a benign renal mass were similar to those with a confirmed RCC.ConclusionsRaising public awareness of RCC-related symptoms as a strategy to improve early detection rates is limited by the fact that related symptoms are relatively uncommon and often associated with advanced disease. Greater attention must be paid to the feasibility of screening strategies and the identification of circulating diagnostic biomarkers.

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ports introduced to enable dissection and identification of the PUJ. The technical principles and goals are similar to those of open surgery. Depending on the type of procedure the PUJ is either incised or dismembered, and reductive pyeloplasty performed if indicated. The ureteric JJ stent is typically inserted retrogradely before (the authors' preference being 4.7 F, 26 cm) or during surgery. A drain is inserted to lie adjacent to the completed repair and a Foley catheter is left in the bladder.Patients typically commence free oral intake of fluids 8-12 h after surgery; the urethral catheter is removed after 1-2 days and the wound drain subsequently. The ureteric stent is typically removed by outpatient flexible cystoscopy at 4 weeks, after IVU. RESULTSThe results of LP are shown in Table 1 [4][5][6][7][8][9][10]; several early reports were excluded where updated results from the same institution were published more recently. Several points are worth specific comment. The success rates of LP are consistently high, at 87-98%; the rates are > 95% in series with a predominance of primary procedures, with only one exception. The 'success rate' is defined as the objective radiological success, i.e. with a patent and unobstructed PUJ (or an improvement in drainage) by either IVU or diuretic renography. Subjective improvement rates, e.g. from patient questionnaires, are invariably less than the radiological success rates by 10-30% for both open and endourological pyeloplasty. There are several possible reasons for this discrepancy, but the present discussion focuses on the objective radiological success rate, which is reported rather more consistently. The prolonged operative duration of reconstructive laparoscopy is significant, but there has been a trend towards a reduction, from a mean of 330 min in the original series to 164-252 min in contemporary series reported in the last 3 years [6][7][8][9]11]. This reflects increased confidence and ability in intracorporeal suturing and knot-tying. Laparoscopic suturing and knot-tying can be learned effectively and reinforced by regular repetition in a 'dry lab' environment. The effect of increasing experience is notable, with an experienced laparoscopist consistently performing the entire procedure (transperitoneal) in < 3.5 h [9]. The retroperitoneal approach (mean operative duration 175 min) is seemingly quicker than the transperitoneal approach (mean 246 min) in contemporary series reported since 2001. This is probably because it takes less time to dissect and identify the PUJ with the retroperitoneal technique. The low morbidity of LP is well reflected in the low incidence of complications during and after surgery even in the initial series. The risks of blood transfusion are remarkably low, being limited to anecdotal reports, in sharp contradistinction to endopyelotomy, where the transfusion rates are 3-11%. The hospital stay is short, averaging 3.8 days in the series reported since 2000.To our knowledge there has been at least one abortive attempt to compare laparosc...

Background: Genomic analysis of multi-focal renal cell carcinomas from an individual with a germline VHL mutation offers a unique opportunity to study tumor evolution. Results: We perform whole exome sequencing on four clear cell renal cell carcinomas removed from both kidneys of a patient with a germline VHL mutation. We report that tumors arising in this context are clonally independent and harbour distinct secondary events exemplified by loss of chromosome 3p, despite an identical genetic background and tissue microenvironment. We propose that divergent mutational and copy number anomalies are contingent upon the nature of 3p loss of heterozygosity occurring early in tumorigenesis. However, despite distinct 3p events, genomic, proteomic and immunohistochemical analyses reveal evidence for convergence upon the PI3K-AKT-mTOR signaling pathway. Four germline tumors in this young patient, and in a second, older patient with VHL syndrome demonstrate minimal intra-tumor heterogeneity and mutational burden, and evaluable tumors appear to follow a linear evolutionary route, compared to tumors from patients with sporadic clear cell renal cell carcinoma.

INTRODUCTION A virtual clinic is a form of telemedicine where contact between clinical teams and patients occur without face-toface consultation. Our study aims to quantify the clinical, financial and environmental benefits of our virtual urology clinic. MATERIAL AND METHODS We collected data prospectively from our weekly follow-up virtual clinic over a continuous four-month period between July and September 2017. RESULTS In total, we reviewed 409 patients. Following virtual clinic consultation, 68.5% of our patients were discharged from further follow-up. The majority of our patients (male 57.7%, female 55.5%) were of working age. The satisfaction scores were high, at 90.1%, and there were no reported adverse events as a result of using the virtual clinic. Our calculated cost savings were £18,744, with a predicted 12-month cost saving of £56,232. The creation of additional face-to-face clinic capacity has created an estimated 12-month increase in tariff generation for our unit of £72,072. In total, 4623 travel miles were avoided by patients using the virtual clinic, with an estimated avoided carbon footprint of 0.35-1.45 metric tonnes of CO 2e , depending on mode of transport. Our predicted 12-month avoided carbon footprint is 1.04-4.04 metric tonnes of CO 2e. CONCLUSIONS Our virtual clinic model has demonstrated a trifecta of positive outcomes, namely, clinical, financial and environmental benefits. The environmental importance and benefits of a virtual clinic should be promoted as a social enterprise value when engaging stakeholders in setting up such a urological service. We propose the adoption of our virtual clinic model in those urological units considering this method of telemedicine.

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Introduction A virtual clinic is a form of telemedicine where contact between clinical teams and patients occur without face-to-face consultation. Our study aims to quantify the clinical, financial and environmental benefits of our virtual urology clinic. Material and methods We collected data prospectively from our weekly follow-up virtual clinic over a continuous four-month period between July and September 2017. Results In total, we reviewed 409 patients. Following virtual clinic consultation, 68.5% of our patients were discharged from further follow-up. The majority of our patients (male 57.7%, female 55.5%) were of working age. The satisfaction scores were high, at 90.1%, and there were no reported adverse events as a result of using the virtual clinic. Our calculated cost savings were £18,744, with a predicted 12-month cost saving of £56,232. The creation of additional face-to-face clinic capacity has created an estimated 12-month increase in tariff generation for our unit of £72,072. In total, 4623 travel miles were avoided by patients using the virtual clinic, with an estimated avoided carbon footprint of 0.35–1.45 metric tonnes of CO2e, depending on mode of transport. Our predicted 12-month avoided carbon footprint is 1.04–4.04 metric tonnes of CO2e. Conclusions Our virtual clinic model has demonstrated a trifecta of positive outcomes, namely, clinical, financial and environmental benefits. The environmental importance and benefits of a virtual clinic should be promoted as a social enterprise value when engaging stakeholders in setting up such a urological service. We propose the adoption of our virtual clinic model in those urological units considering this method of telemedicine.