IMPROVER (Involving Men with Prostate Cancer in Engaged Research): Assessing Patient Experience With Testing, Diagnosis, And Surveillance.

BACKGROUND: Our understanding of patient experiences with prostate cancer testing for diagnosis and surveillance is limited. The aim of this study was to collaborate with patients and clinicians to understand their lived experience and unmet needs around the early detection, diagnosis and monitoring (active surveillance) of prostate cancer. METHODS: Two focus groups were held with patients (n = 20) and healthcare professionals (n = 16), to identify the main challenges in prostate cancer detection, diagnosis, and monitoring. This information formed the basis of an online questionnaire for broader dissemination. RESULTS: A total of 1138 analyzable responses were obtained from people tested for prostate cancer (69% tested positive) in Europe and the US. Only 29 healthcare professionals completed the survey. Almost one-third of people reported knowing very little/nothing about prostate cancer prior to testing. Prior disease awareness was significantly higher in those who tested negative (P < .0001). Most respondents (n = 857; 75%) felt informed about the steps involved in testing. Receiving written information was a key factor; 91% of those who felt uninformed were not given any written information. Overall, most people felt "satisfied" with the typical prostate cancer tests: PSA, DRE, mpMRI, and biopsy. However, dissatisfaction for prostate biopsy (12%) was almost double that of other tests (P < .0001). Most patients understood why each test was done, and felt that their results and next steps were clearly explained to them; though PSA scored lowest in all of these fields. Apart from PSA, test satisfaction was lower when used repeatedly for surveillance, compared to once-off detection/diagnosis. CONCLUSIONS: Greater public awareness and education around prostate cancer, as well as clear and accessible written information for patients at the beginning of their cancer journey is needed. Further research is needed into alternative, less invasive tests, particularly when used repeatedly in the surveillance population.

Nephrectomy for xanthogranulomatous pyelonephritis-a not-so-simple solution.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is a rare chronic inflammatory condition of the kidney, associated with high patient morbidity, often requiring targeted antibiotic therapy and surgical removal of the affected kidney. AIM: We report the outcomes of patients undergoing nephrectomy for XGP in our institution over a 12-year period. METHODS: Following ethical approval, a retrospective review of histological samples of renal tissue demonstrating features of XGP from June 2010 to 2022 was conducted. Laboratory, imaging, and clinical data of included participants were collected. RESULTS: Eleven patients were included (8 women, 3 men), mean age of 58.1 (35-81). Recurrent urinary tract infection was the most common clinical presentation (55%, n = 6). Other presentations included flank pain (36%, n = 4), collection/ abscess (45%, n = 5), and nephro-cutaneous fistulae (9%, n = 1). The majority of patients had bacteriuria (91%, n = 10), and Escherichia coli was the most common bacteria isolated (55%, n = 6). Antibiotic resistance was seen in 60% of positive urine samples (n = 6). An open nephrectomy was performed in all but one case (91%, n = 10). A postoperative complication occurred in 73% (n = 8), with 50% (n = 4) of complications Clavien Dindo grade 3 or higher, including one patient mortality. CONCLUSIONS: XGP is a difficult and complex condition to treat. All patients in this series presented with infection or associated sequelae thereof. Complex XGP cases therefore often require open nephrectomy and have high rates of postoperative complications. Careful consideration of antibiotic and operative intervention is therefore essential to ensure the best outcome for these patients.

Management of Urological Malignancy in Heart and Lung Transplant Recipients: An Irish National Cohort Study.

OBJECTIVES: Following the first hearttransplantin Ireland in 1985, there have been almost 700 deceased donor heart and lung transplants carried out in Ireland at a single institution. In this retrospective study, our aim was to assess the incidence and management of urological malignancies arising in this national cohort. MATERIALS AND METHODS: Our retrospective analysis included all heart and lung transplant recipients identified as having a urological malignancy. Primary outcome variables included incidence, management, and clinical outcomes following cancer diagnosis. RESULTS: A total of 28 patients (4.1%) had radiologically or histologically confirmed urological malignancies. Fourteen patientswere diagnosedwith prostate cancer, with 13 who underwent radical treatment. Eight renal cell carcinomas were diagnosed in heart transplant recipients, with 5 who underwent nephrectomies. Two bladder cancers and 1 uppertract urothelial carcinoma were diagnosed and managed with endoscopic resection, radiotherapy, and nephroureterectomy, respectively. Two patients were diagnosed with penile squamous cell carcinoma and managed with radical surgery and lymph node dissection/sampling, with 1 patient receiving adjuvant chemoradiotherapy. CONCLUSIONS: Urological malignancies are not common in heart and lung transplant recipients; however, standard management options can be safely used, including radical surgery. Prospective monitoring of these patients and potential considerations for screening should be maintained.

Establishing a global quality of care benchmark report.

BACKGROUND: The Movember funded TrueNTH Global Registry (TNGR) aims to improve care by collecting and analysing a consistent dataset to identify variation in disease management, benchmark care delivery in accordance with best practice guidelines and provide this information to those in a position to enact change. We discuss considerations of designing and implementing a quality of care report for TNGR. METHODS: Eleven working group sessions were held prior to and as reports were being built with representation from clinicians, data managers and investigators contributing to TNGR. The aim of the meetings was to understand current data display approaches, share literature review findings and ideas for innovative approaches. Preferred displays were evaluated with two surveys (survey 1: 5 clinicians and 5 non-clinicians, 83% response rate; survey 2: 17 clinicians and 18 non-clinicians, 93% response rate). RESULTS: Consensus on dashboard design and three data-display preferences were achieved. The dashboard comprised two performance summary charts; one summarising site's relative quality indicator (QI) performance and another to summarise data quality. Binary outcome QIs were presented as funnel plots. Patient-reported outcome measures of function score and the extent to which men were bothered by their symptoms were presented in bubble plots. Time series graphs were seen as providing important information to supplement funnel and bubble plots. R Markdown was selected as the software program principally because of its excellent analytic and graph display capacity, open source licensing model and the large global community sharing program code enhancements. CONCLUSIONS: International collaboration in creating and maintaining clinical quality registries has allowed benchmarking of process and outcome measures on a large scale. A registry report system was developed with stakeholder engagement to produce dynamic reports that provide user-specific feedback to 132 participating sites across 13 countries.

A risk calculator to inform the need for a prostate biopsy: a rapid access clinic cohort.

BACKGROUND: Prostate cancer (PCa) represents a significant healthcare problem. The critical clinical question is the need for a biopsy. Accurate risk stratification of patients before a biopsy can allow for individualised risk stratification thus improving clinical decision making. This study aims to build a risk calculator to inform the need for a prostate biopsy. METHODS: Using the clinical information of 4801 patients an Irish Prostate Cancer Risk Calculator (IPRC) for diagnosis of PCa and high grade (Gleason ≥7) was created using a binary regression model including age, digital rectal examination, family history of PCa, negative prior biopsy and Prostate-specific antigen (PSA) level as risk factors. The discrimination ability of the risk calculator is internally validated using cross validation to reduce overfitting, and its performance compared with PSA and the American risk calculator (PCPT), Prostate Biopsy Collaborative Group (PBCG) and European risk calculator (ERSPC) using various performance outcome summaries. In a subgroup of 2970 patients, prostate volume was included. Separate risk calculators including the prostate volume (IPRCv) for the diagnosis of PCa (and high-grade PCa) was created. RESULTS: IPRC area under the curve (AUC) for the prediction of PCa and high-grade PCa was 0.6741 (95% CI, 0.6591 to 0.6890) and 0.7214 (95% CI, 0.7018 to 0.7409) respectively. This significantly outperforms the predictive ability of cancer detection for PSA (0.5948), PCPT (0.6304), PBCG (0.6528) and ERSPC (0.6502) risk calculators; and also, for detecting high-grade cancer for PSA (0.6623) and PCPT (0.6804) but there was no significant improvement for PBCG (0.7185) and ERSPC (0.7140). The inclusion of prostate volume into the risk calculator significantly improved the AUC for cancer detection (AUC = 0.7298; 95% CI, 0.7119 to 0.7478), but not for high-grade cancer (AUC = 0.7256; 95% CI, 0.7017 to 0.7495). The risk calculator also demonstrated an increased net benefit on decision curve analysis. CONCLUSION: The risk calculator developed has advantages over prior risk stratification of prostate cancer patients before the biopsy. It will reduce the number of men requiring a biopsy and their exposure to its side effects. The interactive tools developed are beneficial to translate the risk calculator into practice and allows for clarity in the clinical recommendations.

Admission of patients with acute urinary retention leads to a definitive management decision.

BACKGROUND: Acute urinary retention (AUR) is a common urologic emergency. However, its management is not standardized due to lack of clinical guidelines. AIMS: We retrospectively reviewed the treatment of all male patients admitted to our institution with AUR over 12 months. METHODS: Data was obtained from the HIPE (Hospital Inpatient Enquiry) data system, each patient's electronic discharge summary and from patient medical records. RESULTS: There were 130 AUR admissions during the period. About 74 admissions were due to benign prostatic enlargement (BPE). Of these, 45.9% (n = 34) passed their trial without catheter (TWOC). The remainder (n = 40) failed their TWOC necessitating recatheterization and consideration for transurethral resection of prostate (TURP) or re-TWOC. An indwelling urinary catheter (IDC) was inserted for 27.5% (n = 11) of patients with a failed TWOC secondary to comorbidities. This group had a mean age of 78 years (range 68-96 years). Of those who failed their TWOC, 32.5% (n = 13) had a TURP on index admission. Of the remaining 16 patients with failed TWOC, 75% (n = 12) were discharged with an IDC and readmitted for an elective TURP with a median waiting time of 55 days (range 17-138 days). 18.75% (n = 3) passed a re-TWOC and thus offset the need to have any surgical intervention and 6.25% (n = 1) proceeded to a radical retropubic prostatectomy for biopsy proven prostate adenocarcinoma. CONCLUSION: Admission of patients with acute urinary retention leads to a definitive management decision and reduced prolonged catheterization.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections.

PURPOSE: 'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base. METHODS: A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. RESULTS: We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). CONCLUSIONS: Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Oncological Outcomes of Open Radical Retropubic Prostatectomy in Ireland: A Single Surgeon's 5-Year Experience.

Objectives There is a little published data on the outcomes of radical prostatectomy in the Irish context. We aimed to determine the 5-year oncological results of open radical retropubic prostatectomy (RRP) performed by a single surgeon following appointment. Methods A retrospective review of RRPs performed between 2011 and 2016 was conducted. Patient demographics, preoperative parameters (clinical stage on digital rectal exam, prostate-specific antigen (PSA) levels, biopsy Gleason's score and MRI [magnetic resonance imaging] findings), pathological variables (T-stage, Gleason's score, nodal status, and surgical margin status), and treatment decisions (lymphadenectomy or adjuvant radiotherapy) were recorded. Oncological outcome at last follow-up was ascertained. Results 265 patients underwent RRP between 2011 and 2016. Median age was 62 years (range: 41-74). Mean follow-up was 32.24 months (range: 8-72) months. Pathological disease stage was T2 in 170/265 (64.15%), T3a in 65/265 (24.53%), and T3b in 30/265 (11.32%). Final Gleason's score was upgraded from diagnostic biopsy in 16.35% (43/263) and downgraded in 27% (71/263). Pelvic lymph node dissection was performed in 44.25% (118/265) patients. A positive surgical margin (PSM) was seen in 26/170 (15.2%) patients with T2 disease and in 45/95 (47.37%) patients with T3 disease. Of the 265 patients, 238 (89.81%) were disease-free at last follow-up, of whom 24/238 (10.08%) had received adjuvant and 17/238 (7.14%) received salvage radiotherapy. Adjuvant/salvage treatment was ongoing in 19/265 (7.17%) of patients. Conclusion Good oncological outcomes of RRP in the Irish context are seen in this 5-year review, with the vast majority of patients experiencing biochemical-free survival at most recent follow-up.

Development of Indicators to Assess Quality of Care for Prostate Cancer.

BACKGROUND: The development, monitoring, and reporting of indicator measures that describe standard of care provide the gold standard for assessing quality of care and patient outcomes. Although indicator measures have been reported, little evidence of their use in measuring and benchmarking performance is available. A standard set, defining numerator, denominator, and risk adjustments, will enable global benchmarking of quality of care. OBJECTIVE: To develop a set of indicators to enable assessment and reporting of quality of care for men with localised prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: Candidate indicators were identified from the literature. An international panel was invited to participate in a modified Delphi process. Teleconferences were held before and after each voting round to provide instruction and to review results. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Panellists were asked to rate each proposed indicator on a Likert scale of 1-9 in a two-round iterative process. Calculations required to report on the endorsed indicators were evaluated and modified to reflect the data capture of the Prostate Cancer Outcomes Registry-Australia and New Zealand (PCOR-ANZ). RESULTS AND LIMITATIONS: A total of 97 candidate indicators were identified, of which 12 were endorsed. The set includes indicators covering pre-, intra-, and post-treatment of PCa care, within the limits of the data captured by PCOR-ANZ. CONCLUSIONS: The 12 endorsed quality measures enable international benchmarking on the quality of care of men with localised PCa. Reporting on these indicators enhances safety and efficacy of treatment, reduces variation in care, and can improve patient outcomes. PATIENT SUMMARY: PCa has the highest incidence of all cancers in men. Early diagnosis and relatively high survival rates mean issues of quality of care and best possible health outcomes for patients are important. This paper identifies 12 important measurable quality indicators in PCa care.

Neoadjuvant Platinum-Based Chemotherapy is an Independent Predictor for Preoperative Thromboembolic Events in Bladder Cancer Patients Undergoing Radical Cystectomy.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) confers a significant survival benefit in patients with muscle invasive bladder cancer. Platinum-based chemotherapy increases the risk of thromboembolic events (TEE). We determined the effect of cisplatin-based NAC on the incidence of preoperative TEEs in radical cystectomy patients. MATERIALS AND METHODS: A retrospective matched case-control study was performed on 55 patients undergoing radical cystectomy for muscle invasive bladder cancer. Group 1 (n = 20) included patients that received NAC prior to radical cystectomy and Group 2 (n = 35) included patients that underwent radical cystectomy without NAC. Logistic regression analyses tested potential predictors for TEEs in both groups (age, American Society of Anesthesiologists grade, use of NAC, histological subtype, pathological stage). RESULTS: In total, 6 patients of 55 developed a TEE. Five patients of 20 (25%) treated with NAC prior to radical cystectomy developed TEEs, while 1 of 35 (2.9%) treated with radical cystectomy alone developed a TEE. On univariate and multivariate regression analysis, NAC prior to radical cystectomy was an independent predictor for TEE prior to radical cystectomy (p = 0.033 and p = 0.043, respectively). The effect of perioperative anticoagulation on operative blood loss and postoperative hemoglobin level was not statistically significant between both groups (p = 0.22 and p = 0.08, respectively). CONCLUSION: Neoadjuvant cisplatin-based chemotherapy is a significant predictor for preoperative TEE in patients undergoing radical cystectomy.

Identification and Cost of Disposable Endourological Devices for Nephrolithiasis: A Cross-Sectional Study Among Urological Trainees.

INTRODUCTION: Knowledge on health economics among urology trainees is not formally assessed. The cost of commonly utilised endourological devices may not be considered by trainees. AIM: The present study was conducted with the aim to assess whether urology trainees were knowledgeable on identification and cost of commonly used disposable devices in the management of nephrolithiasis. MATERIALS AND METHODS: Forty urology trainees in Ireland were invited to complete a visual online questionnaire on the identification of 10 frequently utilised disposable endourological devices. In addition, trainees were requested to estimate the cost of 12 disposable endourological devices. Responses were stratified according to trainee grade and urological subspecialty of interest. Data are presented as a mean ± standard deviation. RESULTS: The response rate was 70% (28/40). Endourology was the subspecialty of interest in 21% (n= 6). No trainee correctly identified all 10 endourological devices and the mean test score was 5.32 ± 2.28. No trainee accurately estimated the cost for all 12 devices assessed. The cost of endourological devices was underestimated by €67.13 ± €60.76 per device. A total of 54% (n=15) of trainees underestimated the total cost of disposable devices used during standard flexible ureterorenoscopy, laser lithotripsy and JJ stent insertion by €303.66 ± €113.83. CONCLUSION: Our findings indicate deficiencies in trainee knowledge on endourological devices and their associated costs. Incorporating a health economics module into postgraduate urology training may familiarise trainees with healthcare expenditure within their departments.

European Randomised Study of Screening for Prostate Cancer (ERSPC) risk calculators significantly outperform the Prostate Cancer Prevention Trial (PCPT) 2.0 in the prediction of prostate cancer: a multi-institutional study.

OBJECTIVE: To analyse the performance of the Prostate Cancer Prevention Trial Risk Calculator (PCPT-RC) and two iterations of the European Randomised Study of Screening for Prostate Cancer (ERSPC) Risk Calculator, one of which incorporates prostate volume (ERSPC-RC) and the other of which incorporates prostate volume and the prostate health index (PHI) in a referral population (ERSPC-PHI). PATIENTS AND METHODS: The risk of prostate cancer (PCa) and significant PCa (Gleason score ≥7) in 2001 patients from six tertiary referral centres was calculated according to the PCPT-RC and ERSPC-RC formulae. The calculators' predictions were analysed using the area under the receiver-operating characteristic curve (AUC), calibration plots, Hosmer-Lemeshow test for goodness of fit and decision-curve analysis. In a subset of 222 patients for whom the PHI score was available, each patient's risk was calculated as per the ERSPC-RC and ERSPC-PHI risk calculators. RESULTS: The ERSPC-RC outperformed the PCPT-RC in the prediction of PCa, with an AUC of 0.71 compared with 0.64, and also outperformed the PCPT-RC in the prediction of significant PCa (P<0.001), with an AUC of 0.74 compared with 0.69. The ERSPC-RC was found to have improved calibration in this cohort and was associated with a greater net benefit on decision-curve analysis for both PCa and significant PCa. The performance of the ERSPC-RC was further improved through the addition of the PHI score in a subset of 222 patients. The AUCs of the ERSPC-PHI were 0.76 and 0.78 for PCa and significant PCa prediction, respectively, in comparison with AUC values of 0.72 in the prediction of both PCa and significant PCa for the ERSPC-RC (P = 0.12 and P = 0.04, respectively). The ERSPC-PHI risk calculator was well calibrated in this cohort and had an increase in net benefit over that of the ERSPC-RC. CONCLUSIONS: The performance of the risk calculators in the present cohort shows that the ERSPC-RC is a superior tool in the prediction of PCa; however the performance of the ERSPC-RC in this population does not yet warrant its use in clinical practice. The incorporation of the PHI score into the ERSPC-PHI risk calculator allowed each patient's risk to be more accurately quantified. Individual patient risk calculation using the ERSPC-PHI risk calculator can be undertaken in order to allow a systematic approach to patient risk stratification and to aid in the diagnosis of PCa.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes.

INTRODUCTION: We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN). METHODS: We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS: The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement. CONCLUSIONS: The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Renal Trauma: The Rugby Factor.

INTRODUCTION: Renal trauma accounts for 5% of all trauma cases. Rare mechanisms of injuries including sports participation are increasingly common. Rugby-related trauma poses a conundrum for physicians and players due to the absence of clear guidelines and a paucity of evidence. Our series highlights traumatic rugby-related renal injuries in our institution, and emphasize the need for international guidelines on management. METHODS: A retrospective review of all abdominal traumas between January 2006 and April 2013, specifically assessing for renal related trauma that were secondary to rugby injuries was performed. All patients' demographics, computerized tomography results, hematological and biochemical results and subsequent management were recorded. RESULTS: Five male patients presented with rugby-related injuries. Mean age was 21 years old. All patients were hemodynamically stable and managed conservatively in acute setting. One patient was detected to have an unknown pre-existing atrophic kidney that had been subsequently injured, and was booked for an elective nephrectomy an 8-week interval. CONCLUSION: Rugby-related trauma has generated essential attention. This paper serves to highlight this type of injury and the need for defined guidelines on role of imaging and international consensus on timing of return to contact sport, in both professional and amateur settings.

Clinico-pathological analysis of renal cell carcinoma demonstrates decreasing tumour grade over a 17-year period.

INTRODUCTION: Renal cell carcinoma (RCC) represents about 3% of adult malignancies in Ireland. Worldwide there is a reported increasing incidence and recent studies report a stage migration towards smaller tumours. We assess the clinico-pathological features and survival of patients with RCC in a surgically treated cohort. METHODS: A retrospective analysis of all nephrectomies carried out between 1995 and 2012 was carried out in an Irish tertiary referral university hospital. Data recorded included patient demographics, size of tumour, tumour-node-metastasis (TNM) classification, operative details and final pathology. The data were divided into 3 equal consecutive time periods for comparison purposes: Group 1 (1995-2000), Group 2 (2001-2006) and Group 3 (2007-2012). Survival data were verified with the National Cancer Registry of Ireland. RESULTS: In total, 507 patients underwent nephrectomies in the study period. The median tumour size was 5.8 cm (range: 1.2-20 cm) and there was no statistical reduction in size observed over time (p = 0.477). A total of 142 (28%) RCCs were classified as pT1a, 111 (21.9%) were pT1b, 67 (13.2%) were pT2, 103 (20.3%) were pT3a, 75 (14.8%) were pT3b and 9 (1.8%) were pT4. There was no statistical T-stage migration observed (p = 0.213). There was a significant grade reduction over time (p = 0.017). There was significant differences noted in overall survival between the T-stages (p < 0.001), nuclear grades (p < 0.001) and histological subtypes (p = 0.022). CONCLUSION: There was a rising incidence in the number of nephrectomies over the study period. Despite previous reports, a stage migration was not evident; however, a grade reduction was apparent in this Irish surgical series. We can demonstrate that tumour stage, nuclear grade and histological subtype are significant prognosticators of relative survival in RCC.

Sexual function outcomes following fracture of the penis.

INTRODUCTION: Fracture of the penis is a rare urological emergency which occurs as a result of abrupt trauma to an erect penis. There is paucity of data regarding long-term sexual function or erectile potency following fracture of the penis. The aim of this study is to objectively assess the overall sexual function following fracture of the penis. METHODS: A retrospective analysis of 21 penile fractures was performed. A voluntary telephone questionnaire was performed to assess long term outcomes using three validated questionnaires-the Erection Hardness Grading Scale, the International Index of Erectile Function (IIEF-5) and the Brief Male Sexual Function inventory (BMSFI). RESULTS: The mean age was 33.1 years (range: 19-63). The median follow up was 46 months (range: 3-144). All fractures were a result of sexual misadventure and all were surgically repaired. There were two concomitant urethral injuries. Seventeen patients were contactable. Fourteen patients demonstrated no evidence of erectile dysfunction (ED) (IIEF-5>22), 1 patient reported symptoms of mild ED (IIEF-5, 17-21) and one patient reported mild to moderate ED (IIEF-5, 12-16). No patients reported insufficient erection for penetration (EHGS: 1 or 2). Regarding the overall BMSFI, 13 (83%) patients were mostly satisfied or very satisfied with their sex life within the previous month. CONCLUSION: In a small surgical series of men with penile fracture managed within a short time frame from presentation, we demonstrate erectile potency is maintained. Long-term overall sexual satisfaction is promising.

Can delayed time to referral to a tertiary level urologist with an abnormal PSA level affect subsequent Gleason grade in the opportunistically screened population?

PURPOSE: There is growing conflict in the literature describing the effect of delayed treatment on outcomes following radical prostatectomy. There is also evidence to suggest progression of low-risk prostate cancer to develop higher grades and volumes of prostate cancer during active surveillance. It is unknown as to what affect a delay in referral of those men with abnormal screened-PSA levels have on subsequent Gleason grade. METHODS: We identified 350 men through our rapid access prostate clinic who underwent TRUS biopsy for abnormal age-related PSA and/or abnormal clinical examination. Clinicopathological findings were compared for those with positive versus negative TRUS biopsies, and for those with initial delays in referral (<12 months, 12-18 months, and >18 months). We used ANOVA and Student's t-tests amongst other statistical tools to examine significance of clinical findings. RESULTS: Of the 350 men who underwent TRUS biopsy, those with a delay in referral of 12 months or more were significantly associated with higher PSA titers, clinically palpable disease and likelihood of diagnosis with prostate cancer. A delay of 18 months or more led to a significantly higher risk of being diagnosed with a leading grade 4 prostate cancer, which was further supported using PSA velocity as a diagnostic tool (change >0.4 ng/ml/year). CONCLUSION: We recommend that repeated asymptomatic abnormal age-related PSA readings and/or abnormal clinical examination in the screened population be referred without delay to a urologist for further assessment, enrolment into an active surveillance program or definitive subsequent treatment.