BackgroundMultiparametric magnetic resonance imaging (mpMRI) is now recommended pre-biopsy in numerous healthcare regions based on the findings of high-quality studies from expert centres. Concern remains about reproducibility of mpMRI to rule-out clinically significant prostate cancer (csPCa) in real-world settings. ObjectiveTo assess the diagnostic performance of mpMRI for csPCa in a real-world setting. Design, Setting, and ParticipantsA multicentre, retrospective cohort study including men referred with a raised PSA or abnormal digital rectal exam who had undergone mpMRI followed by transrectal or transperineal biopsy. Patients could be biopsy naïve or have had previous negative biopsies. Outcome Measurements and Statistical AnalysisThe primary definition for csPCa was defined as ISUP Grade Group 2 or higher (any Gleason >/=7); the accuracy for other definitions was also evaluated. Results and LimitationsAcross 10 sites 2642 men were included (January/2011-November/2018). Mean age and PSA were 65.3 years (SD 7.8 years) and 7.5ng/ml (SD 3.3ng/ml). 35.9% had a 'negative' MRI' (score 1-2). 51.9% underwent transrectal biopsy and 48.1% had transperineal biopsy; with 43.4% diagnosed with csPCa overall. The sensitivity and negative predictive value (NPV) for 5 ISUP GG >/=2 were 87.3% and 87.5%, respectively. The NPV was 87.4% and 88.1% for men undergoing transrectal and transperineal biopsy, respectively. Specificity and positive predictive value of MRI were 49.8% and 49.2%, respectively. The sensitivity and NPV increased to 96.6% and 90.6% when a PSA-density threshold 0.15ng/ml/ml was used in MRI scores 1-2; these metrics increased to 97.5% and 91.2%, respectively, for PSA density 0.12ng/ml/ml. ISUP GG >/=3 (Gleason >/=4+3) was found in 2.4% (15/617) of men with MRI score 1-2. They key limitation of this study is the heterogeneity and retrospective nature of the data. ConclusionsmpMRI when used in real-world settings is able to accurately rule-out csPCa suggesting that about one-third of men might avoid an immediate biopsy. Men should be counselled about the risk of missing some significant cancers.

Innovation in recent times has accelerated due to factors such as the globalization of communication; but there are also more barriers/ safeguards in place than ever before as we strive to streamline this process.From the first planned partial nephrectomy completed in 1887, it took over a century to become recommended practice for small renal tumours. At present, identified areas for improvement/ innovation are 1) to preserve renal parenchyma, 2) to optimise pre-operative eGFR and 3) to reduce global warm ischaemia time. All 3 of these, are statistically significant predictors of post-operative renal function. As ever, our predictions of the future may well fall wide of the mark, but in order to progress, one must open the mind to the possibilities that already exist, as evolution of existing technology often appears to be a revolution in hindsight.

Calcific uremic arteriolopathy or calciphylaxis is a rare condition that can present with clinical features similar to penile cancer. It is a diagnosis to consider in patients with end-stage renal failure (ESRF) presenting with a penile lesion. We describe one such case, where a patient with ESRF presented with a solid, tender penile mass and underwent surgery for presumed penile cancer. Histopathological analysis however confirmed a diagnosis of calcific uremic arteriolopathy, without evidence of malignancy. The clinical diagnosis of calcific uremic arteriolopathy relies on a high index of suspicion, and lesion biopsy is controversial due to a high risk of poor wound healing and sepsis. New treatment options are encouraging, and have been reported, albeit in small numbers. Delayed diagnosis can adversely affect both quality of life and prognosis in a condition with an extremely high mortality rate.

Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not always the case.The indications for partial nephrectomy continue to expand and it is becoming particularly relevant in patients with single functioning kidneys, poor kidney function, anatomical anomalies and hereditary syndromes predisposing to multiple kidney cancers, such as Von Hippel-Lindau syndrome. These, along with previous abdominal surgery, pose surgical challenges. In this article we offer advice as to how to tackle these unusual situations.An ability to master the whole range of indications will allow the modern upper renal tract surgeon to offer partial nephrectomy to a wider range of patients.