In an article published in Archives of Paediatrics and Adolescent Medicine (2012) the authors report that the rate of circumcision in newborn males had dropped from 79% in 1970s to 55% in 2010 in USA. For comparison, in UK there is a 16% circumcision rate and less than 2% in Denmark. This 20 year decline had already cost an estimated $20bn largely in the cost of treating added HIV infection, urinary tract infection in infants and adult HPV infection.
Following a German court ruling in June 2012 that described circumcision in a 4 year old Muslim boy as violating his fundamental human right to bodily integrity, an appeal to the German ethics council unanimously supported religious circumcision as long as 4 conditions were met:-
1) that both parents were in agreement
2) that the boy did not veto the procedure
3) that the procedure was performed by a suitably trained practitioner
4) that suitable pain relief was provided
In an article published in New Eng J Med (2012) the authors describe a placebo controlled trial using enzalutamide in castrate resistant prostate cancer. 1199 men were recruited; two thirds received 160 mg enzalutamide daily while the rest took placebo. The trial was stopped early, after 520 men had died, because a pre-planned analysis showed the drug’s superiority over placebo. Median survival with enzalutamide was 18.4 months, whereas with placebo this was 13.6 months. All the secondary outcomes also favoured the drug. These included the proportion of men in whom levels of prostate specific antigen (PSA) at least halved during the study (54% with enzalutamide v 2% with placebo), quality of life, and time to progression of the disease accompanied by a predefined rise in PSA (8.3 months v 3.0 months).
NICE have issued new guidelines for the management of lower urinary tract dysfunction in neurological disease. These are available at the NICE website. The guidelines include taking a history, assessing the impact of problems and screening for urinary tract infection and renal insufficiency. Urgent referral for a specialist opinion is required if there is:
2) recurrent urinary infection (3 or more in 6 months)
3) loin pain
4) progressive renal insufficiency or hydronephrosis on ultrasound.
6) frequent blocking of urinary catheters (more frequent than every 6 weeks)
The guidelines then discuss specialist investigations, including video urodynamics, treatment and longterm monitoring, including lifelong annual or biannual ultrasound monitoring of the renal tract in those at risk of hydronephrosis (these include people with spinal cord injury, spina bifida, or adverse features on urodynamic investigations such as impaired bladder compliance, detrusor-sphincter dyssynergia, or vesicoureteric reflux).
The Staffordshire Urology clinic website has now had 3000 unique visitors and almost 4000 visitors in total. In addition to almost 10,000 comments to its blog, there have been over 10,500 page views.
In an article by Thangasamy et al published in Eur Urol (2012) the authors describe the results of a meta-analysis of the results of photoselective vaporisation of the prostate (PVP) also known as Green Light Laser prostate surgery, compared to Transurethral resection of the prostate (TURP). 9 trials were identified with 448 patients treated with PVP, and 441 with TURP. Period of post-op catheterisation, blood loss and blood transfusion were significantly better with PVP, although operating time was longer. Regarding functional outcomes, 6 studies found no difference, 2 favoured TURP and 1 favoured PVP, with variable follow-up between 6 and 36 months.
The Redeem study was set up to investigate whether dutesteride is effective in treating men with low risk (PSA <11 and Gleason score 6 or less) prostate cancer. Results published in Lancet (2012) suggest that, in this randomised controlled double blind trial of 302 pateints (147 actively treated with 155 matching placebo treated men), prostate cancer progression was reduced in those patients recieving 0.5mg dutesteride daily. Approximatly 1/3 of the treated patients progressed compared to 1/2 of those not treated. Mortality and adverse events were similar in both groups at 3 years.
In an interesting case-control studyby Wright et al published in Cancer (2012) the authors found a 15% reduction in prostate cancer risk in patients circumcised before first sexual intercourse. The study included 1754 prostate cancer cases and 1645 controls. Approximately 17% of all cancers are caused by infection and there is already other epidemiological evidence linking sexually transmitted infection (STI) to prostate cancer. This publication reinforces the causal relationship between STI and prostate cancer.
Since its launch at the end of November 2011, the Staffordshire Urology Clinic website has attracted over 10,000 page views and the associated blog (available at the website/Twitter/Facebook/RSS) has attracted over 6,500 comments. About 50% of page views last for more than 3 minutes indicating considerable user engagement.
In a meta analysis of 13 randomised trials published in Arch Int Med (2012) the authors showed that Cranberry products probably do help prevent urinary tract infections. A significant effect emerged from pooled analyses that excluded one outlying trial (risk ratio 0.62, 95% CI 0.49 to 0.80), confirming results from a previous much smaller meta-analysis. The effect is greatest for individuals taking more than 2 doses per day, younger women and children. The effect is less strong for the elderly, pregnant and patients with neuropathic bladder dysfunction. Cranberries (genus Vaccinium) have been used as a natural remedy for at least 100 years, and in the 1980s scientists discovered that the berries contain an active ingredient (possibly proanthocyanidins) that stops bacteria sticking to uroepithelial cells.
In a separate report published as a Cochraine review (2012) the researchers concluded that current evidence did not support a preventative role for cranberry juice.