Current opinion in urology
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Prostate cancer remains the commonest nondermatological cause of cancer in Western men and the second leading cause of cancer death in these men. While low and intermediate-risk prostate cancers make up the vast bulk of prostate cancer diagnoses, it is high-risk prostate cancer that is a much larger killer. Management paradigms for such disease are changing and thus we review the current state of play with the management of these cancers and what the future might hold. ⋯ The increasing use of radical extirpative surgery might negatively impact functional outcomes but are likely to prolong lives of high-risk prostate cancer sufferers, though more research from well conducted randomized controlled trials is needed to exactly define which patient subpopulations should receive which therapies, in which orders, and at what times.
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High-risk prostate cancer (PCa) harbours a risk of local, regional and systemic relapse requiring the combination of a loco-regional treatment such as external beam radiotherapy for controlling the pelvic-confined disease, combined with an androgen deprivation therapy (ADT) to potentiate irradiation and to destroy the infraclinical androgen-dependent disease outside the irradiated volume. ⋯ For locally advanced PCa, the combination needs a long-term ADT (≥2 years) with luteinizing hormone-releasing hormone agonists. For high-risk localized PCa, the combination requires a 6-month complete androgen blockade. Image-guided intensity-modulated radiotherapy has replaced conventional irradiation and allows a dose escalation, improving the local control without increasing the toxicity. A multidisciplinary approach will enable physicians to tailor the treatment policy and a close cooperation with general practitioners and specialists will be set up to prevent as much as possible the side-effects of ADT.
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Over the past 10 years, we have seen major advances in urological imaging including developments in digital imaging, ultrasound and computerized tomography (CT) scanning. All of these have had an impact on the management of urinary tract stone disease. In parallel with these, we have witnessed a greater appreciation of the potential harm of irradiation exposure. In this article, we aim to provide an overview of the impact of imaging in urolithiasis treatment planning in 2013. ⋯ A detailed understanding of the performance of all the imaging modalities available to the stone surgeon in 2013 is vital in order to offer well tolerated and effective imaging strategies for all stages of the patient journey. CT has developed a pre-eminent role in the diagnosis of urinary stone disease, it has also found favour as a valuable surgical planning tool and is being advocated in the surveillance protocols. However, we must keep in mind the risks of radiation exposure in a patient population characterized by youth and a susceptibility to repeated acute disease episodes.
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Mesh used for slings and pelvic organ prolapse (POP) repair has resulted in increased efficacy. Yet, the benefits of a more durable repair must be weighed against such risks as vaginal mesh extrusion and erosion and increased dyspareunia, and pelvic pain. We review the current literature on complications seen with the use of vaginal mesh for both stress urinary incontinence and POP. ⋯ Better-controlled data are needed to answer questions regarding outcomes, complications, and quality of life after transvaginal mesh prolapse procedures. The surgeon and the patient must have a proper informed consent discussion about the risks, benefits, alternatives, and indications for the use of mesh.