It is nearly 40 years since Bacillus Calmette–Guérin (BCG) was first used as an immunotherapy to treat superficial bladder cancer. Despite its limitations, to date it has not been surpassed by any other treatment. As a better understanding of its mechanism of action and the clinical response to it have evolved, some of the questions around optimal dosing and treatment protocols have been answered. However, its potential for toxicity and failure to produce the desired clinical effect in a significant cohort of patients presents an ongoing challenge to clinicians and researchers alike. This review summarizes the evidence behind the established mechanism of action of BCG in bladder cancer, highlighting the extensive array of immune molecules that have been implicated in its action. The clinical aspects of BCG are discussed, including its role in reducing recurrence and progression, the optimal treatment regime, toxicity and, in light of new evidence, whether or not there is a superior BCG strain. The problems of toxicity and non-responders to BCG have led to development of new techniques aimed at addressing these pitfalls. The progress made in the laboratory has led to the identification of novel targets for the development of new immunotherapies. This includes the potential augmentation of BCG with various immune factors through to techniques avoiding the use of BCG altogether; for example, using interferon-activated mononuclear cells, BCG cell wall, or BCG cell wall skeleton. The potential role of gene, virus, or photodynamic therapy as an alternative to BCG is also reviewed. Recent interest in the immune check point system has led to the development of monoclonal antibodies against proteins involved in this pathway. Early findings suggest benefit in metastatic disease, although the role in superficial bladder cancer remains unclear.

The kidney is the most commonly injured genitourinary organ, and renal involvement has been reported in 1-5% of all trauma cases. Two mechanisms of renal injury are described, namely blunt (direct blow to the kidney, rapid acceleration/ deceleration or a combination) and penetrating (from stab or gunshot wounds), with blunt injuries being most common in the UK. It is important to keep an index of suspicion for renal trauma as given by the mechanism of the injury or in polytrauma. Accurate assessment and resuscitation are vital in the initial management. Imaging with computed tomography is critical to the accurate grading of the injury and helps guide subsequent treatment. The approach to management of renal injuries has changed over time. During the past two decades, advances in cross-sectional imaging coupled with minimally invasive intervention strategies (like angiography, embolisation and ureteric stenting) for managing traumatic renal injuries have allowed increased renal preservation by reducing the need for major surgical intervention. Nowadays, the vast majority of blunt injuries (up to 95%) are managed conservatively with accumulated experience suggesting this is safe. However, there is still a role for open surgical exploration in patients with haemodynamic instability or those who fail initial conservative/minimally invasive management.

What's known on the subject? and What does the study add?• PSA testing has resulted in a large number of patients being referred to urologists for investigation of potential prostate cancer. Despite limited evidence, non-physician providers now perform a number of routine urological procedures such as transrectal ultrasound-guided prostatic biopsies (TRUSP) in a bid to help relieve this increasing workload.• In the largest series to date, we provide evidence that an adequately trained non-physician provider is able to perform TRUSP as effectively as an experienced urologist after an initial learning curve. Objective• To evaluate differences in cancer detection rates between a trained non-physician provider (NPP) and an experienced urologist performing transrectal ultrasound-guided prostatic biopsies (TRUSP) at a single UK institution. Patients and Methods• We retrospectively analysed a prospectively accrued database of patients (n = 440) referred for investigation of an abnormal digital rectal examination and/or a raised age-specific prostate-specific antigen (PSA) value undergoing first-time outpatient prostatic biopsies who were sequentially allocated to either an NPP or a physician-led TRUSP clinic.• Differences in overall and risk-stratified prostate cancer detection rates were evaluated according to TRUSP operator.• Continuous variables were analysed using Mann-Whitney U test whereas categorical variables were analysed using Pearson's chi-squared test. A multivariate binary logistic regression model was fitted for predictors of a positive biopsy. Results• In all, 57.3% (126/220) of patients who underwent physician-led TRUSP were diagnosed with prostate cancer compared with 52.7% (116/220) in the NPP-led clinic (P = 0.338).• Sub-group analysis revealed a lower cancer detection rate in men presenting with a low PSA level (<9.9 ng/mL) during the first 50 independent TRUSP procedures performed by the NPP (P = 0.014). This initial difference was lost with increasing case volume, suggesting the presence of a learning curve.• Multivariate logistic regression analysis revealed age (odds ratio (OR) 1.054, 95% confidence interval (95% CI) 1.025-1.084, P Յ 0.001), presenting PSA level (OR 1.05, 95% CI 1.02-1.081, P = 0.001), prostatic volume (OR 0.969, 95% CI 0.958-0.981, P Յ 0.001) and clinical stage (OR 1.538, 95% CI 1.046-2.261, P = 0.029) to be predictors of a positive prostatic biopsy outcome.• The choice of TRUSP operator was not predictive of a positive prostatic biopsy (OR 0.729, 95% CI 0.464-1.146, P = 0.171). Conclusion• An adequately trained NPP is able to perform TRUSP as effectively as an experienced urologist after an initial learning curve of 50 cases.

Introduction: In kidney transplantation, total laparoscopic live donor nephrectomy (TLLDN) in the presence of multiple renal arteries (MRA) is technically challenging and has traditionally been associated with higher complication rates. We report our experience of using MRA grafts procured by TLLDN. Materials and Methods: Patients undergoing TLLDN at our center (2004–2014) was identified from a prospectively maintained database and divided into single renal arteries (SRA) or MRA groups. Recipient perioperative parameters, postoperative complications, and long-term graft survival were analyzed. Results: Of 465 patients, 106 had MRA and 359 had an SRA. There were six vascular complications in the SRA group and two in the MRA group (1.7% vs. 1.8%). There were eight ureteric complications requiring intervention in the SRA group compared to three in the MRA group (4% vs. 3%; P = 0.45). Acute rejection was observed in 12% of the SRA group compared to 9% in the MRA group ( P = 0.23). One-, 5- and 10-year graft survivals were 98.2%, 91.3%, and 89.8% in the MRA group versus 98.0%, 90.4%, and 77.5% in the SRA group (log-rank P = 0.13). Conclusion: The use of MRA grafts procured by TLLDN has comparable complication rates to SRA grafts and should not preclude selection for renal transplantation.

EditorialWith the increase of routine ultrasound and cross-sectional imaging there has been an increase in the number of small renal masses worldwide. 1,5 Due to this trend there is migration on the diagnosis of smaller renal masses that localized lesions, which has allowed for urologists to pursue nephron-sparing approaches to treatment, including partial nephrectomy and targeted in situ ablation. 2 Laparoscopic partial nephrectomy (LPN) similarly offers equivalent disease-specific outcomes but with shortened convalescence compared with OPN. 3 However, LPN is a technically challenging procedure that requires advanced laparoscopic skills and, in the vast majority of cases, the need for renal hilar occlusion. 4,5,7 In an attempt to shorten the considerable learning curve associated with LPN, to ease surgeon fatigue, and to further expand indications set for LPN, robotic partial nephrectomy (RPN) has been introduced. Outcomes of early experience reports have thus far have been favourable. 5,6 In the UK there is a variation in the number of LPN and RPN being performed throughout the country. To establish current practice of either technique we developed a questionnaire, which was sent to all Urological cancer units in the UK in March 2013 with a request of all participating urological surgeons to return the survey within 3 months of receipt. Prior to sending the questionnaire each cancer centre was individually telephone by both the first and second authors of this paper. A 73 % response was received from national experts in the UK performing either LPN (Group 1) or RPN (Group 2). All data collected included selection criteria, pre-operative scoring, details of surgical technique, average warm ischemia time and approximate complication rate.The results of the survey indicated that surgeons in Group 1 (LPN) consisted of 19 Surgeons who have performed a total of 465 LPN from June 2002 until November 2012. All surgeons select tumour < 4cm in size which are at least 50 % exophytic. Ten percent of surgeons use the RENAL scorings system. The control of the renal hilum was with the lap bulldog (50 %), lap satinsky (20 %), rummell loop (10 %) and no clamp (10 %). The mean warm ischemia time was 16.6 minutes (Range 0 -30). The mean incidence of urinoma was 2.4 % (Range 2-15), AV Fistula 0.6 % (Range 0 -3) and emergency nephrectomy was 0.5 % (0 -4). Twenty percent of surgeons perform Retroperitoneal LPN.In Group 2 (RPN) there were only 7 surgeons which indicates that RPN is only being performed by a select few centres in the UK and is a relatively new procedure who have performed a total of 227 RPN from January 2008 until November 2012. All surgeons selected tumour < 5 cm which were technically feasible. Fifty seven percent of surgeons use a scorings system i.e. RENAL or PADUA. The mean warm ischemia time was 15.3 minutes (Range 0 -27). The control of the renal hilum was with the lap bulldog (100 %). The mean incidence of urinoma was 1 (Range 0 -5), AV Fistula 0.5 % (Range 0 -5) and emergency nephrectomy was 0. None of su...