COmparing Urolift and Standard Transurethral resection of prostate Ahead of Radiotherapy in men with urinary symptoms secondary to prostate enlargement in Southwest London and North Cumbria (CO-STAR): a study protocol for a randomised feasibility study.

INTRODUCTION: Patients undergoing prostate radiotherapy with an enlarged prostate can have short-term and long-term urinary complications. Currently, transurethral resection of the prostate (TURP) is the mainstay surgical intervention for men with urinary symptoms due to an enlarged prostate prior to radiotherapy. UroLift (NeoTract, Pleasanton, CA, USA) is a recent minimally invasive alternative, widely used in benign disease but is untested in men with prostate cancer. METHODS AND ANALYSIS: A multicentre, two-arm study designed in collaboration with a Patient Reference Group to assess the feasibility of randomising men with prostate cancer and coexisting urinary symptoms due to prostate enlargement to TURP or UroLift ahead of radiotherapy. 45 patients will be enrolled and randomised (1:1) using a computer-generated programme to TURP or UroLift. Recruitment and retention will be assessed over a 12 month period. Information on clinical outcomes, adverse events and costs will be collected. Clinical outcomes and patient reported outcome measures will be measured at baseline, 6 weeks postintervention and 3 months following radiotherapy. A further 12 in-depth interviews will be conducted with a subset of patients to assess acceptability using the Theoretical Framework of Acceptability. Descriptive analysis on all outcomes will be performed using Stata (StataCorp V.2021). ETHICS AND DISSEMINATION: The trial has been approved by the Research Ethics Committee (REC) NHS Health Research Authority (HRA) and Health and Care Research Wales (HCRW). The results will be published in peer-reviewed journals, presented at national meetings and disseminated to patients via social media, charity and hospital websites. TRIAL REGISTRATION NUMBER: NCT05840549.

Mobile Health Solutions for Prostate Cancer Diagnostics-A Systematic Review.

Prostate cancer, the most common cause of cancer in men in the UK and one of the most common around the world to date, has no consensus on screening. Multiple large-scale trials from around the world have produced conflicting outcomes in cancer-specific and overall mortality. A main part of the issue is the PSA test, which has a high degree of variability, making it challenging to set PSA thresholds, as well as limited specificity. Prostate cancer has a predisposition in men from black backgrounds, and outcomes are worse in men of lower socioeconomic groups. Mobile targeted case finding, focusing on high-risk groups, may be a solution to help those that most need it. The aim of this systematic review was to review the evidence for mobile testing for prostate cancer. A review of all mobile screening studies for prostate cancer was performed in accordance with the Cochrane guidelines and the PRISMA statement. Of the 629 unique studies screened, 6 were found to be eligible for the review. The studies dated from 1973 to 2017 and came from four different continents, with around 30,275 men being screened for prostate cancer. Detection rates varied from 0.6% in the earliest study to 8.2% in the latest study. The challenge of early diagnosis of potentially lethal prostate cancer remains an issue for developed and low- and middle-income countries alike. Although further studies are needed, mobile screening of a targeted population with streamlined investigation and referral pathways combined with raising awareness in those communities may help make the case for screening for prostate cancer.

Detection rates of recurrent prostate cancer: 68Gallium (Ga)-labelled prostate-specific membrane antigen versus choline PET/CT scans. A systematic review.

BACKGROUND: The aim of this work was to assess the use of prostate-specific membrane antigen (PSMA)-labelled radiotracers in detecting the recurrence of prostate cancer. PSMA is thought to have higher detection rates when utilized in positron emission tomography (PET)/computed tomography (CT) scans, particularly at lower prostate-specific antigen (PSA) levels, compared with choline-based scans. METHODS: A systematic review was conducted comparing choline and PSMA PET/CT scans in patients with recurrent prostate cancer following an initial curative attempt. The primary outcomes were overall detection rates, detection rates at low PSA thresholds, difference in detection rates and exclusive detection rates on a per-person analysis. Secondary outcome measures were total number of lesions, exclusive detection by each scan on a per-lesion basis and adverse side effects. RESULTS: Overall detection rates were 79.8% for PSMA and 66.7% for choline. There was a statistically significant difference in detection rates favouring PSMA [OR (M-H, random, 95% confidence interval (CI)) 2.27 (1.06, 4.85), p = 0.04]. Direct comparison was limited to PSA < 2 ng/ml in two studies, with no statistically significant difference in detection rates between the scans [OR (M-H, random, 95% CI) 2.37 (0.61, 9.17) p = 0.21]. The difference in detection on the per-patient analysis was significantly higher in the PSMA scans (p < 0.00001). All three studies reported higher lymph node, bone metastasis and locoregional recurrence rates in PSMA. CONCLUSIONS: PSMA PET/CT has a better performance compared with choline PET/CT in detecting recurrent disease both on per-patient and per-lesion analysis and should be the imaging modality of choice while deciding on salvage and nonsystematic metastasis-directed therapy strategies.

Malignant transformation of a urachal cyst-a case report and literature review.

Urachal remnant diseases are very uncommon pathologies which are mostly benign. Rarely they can progress to a very aggressive form of Urachal cancer. The rarity of this condition has precluded large studies to help guide the diagnostic and therapeutic management of these potentially malignant lesions. In this case, a urachal cyst was discovered and conservative management was employed after a biopsy proved the lesion was benign. Unfortunately this patient represented several years later with a locally advanced urachal cancer. To date, this is the first clearly documented case of malignant transformation. The available literature surrounding these urachal cysts and cancers will be reviewed to determine if anything could have been done differently in this case and in the future should a similar case present.

Epididymo-orchitis causing testicular infarction: a serious complication of a common disorder.

One of the most common differentials for the acute scrotum is an epididymo-orchitis (EO), which can mimic the presentation of testicular torsion. We present a case of a 37-year-old man presented to the Emergency department with a 3-day history of progressive left testicular pain. A Doppler ultrasound was done which revealed increased flow to the left testicle with no evidence of testicular torsion and he was discharged. He was re-admitted with worsening pain and a repeat scan showed that the penile arterial diastolic flow had reversed, indicating testicular infarction. This was confirmed at exploration and an orchidectomy was performed. EO causing severe complications is an uncommon manifestation of a common disorder. Features suggesting a lack of response to antibiotics include sepsis, pronounced scrotal oedema, severe testicular pain and scrotal wall inflammation. The presence of a positive urine culture has also been highlighted as a poor prognostic factor.

Republished: instigating change: trainee doctors' perspective.

In the 21st century, the core skills of trainee doctors are evolving as clinicians, leaders and innovators. Leadership skills are an essential tool for all doctors and need to be an integral part of their training and learning as set out in the General Medical Council's Good Medical Practice. It is essential to develop these skills at an early stage and continually improve them. A group of junior doctors participated in a pilot programme for leadership with the aim of executing a quality improvement (QI) project. This article describes our experiences of both the course itself and the project undertaken by our group. As part of the process of implementing change, we faced a number of challenges which contributed to our learning. These have been explored as well as potential ways to overcome them to enable the swift and smooth development of future QI projects. Using an example of a QI project looking at handover, this article demonstrates how a trainee doctor can implement their project for both professional and institutional improvement.

Glomerular filtration rate in prospective living kidney donors.

PURPOSE: Measurements of glomerular filtration rate (GFR) are frequently interpreted assuming a linear variation with age. Nonlinear relationships may give a better representation of the changes associated with normal ageing. METHODS: This was a retrospective study of 904 subjects (468 women, 436 men; age range 18-84 years) undergoing assessment as prospective living kidney donors. GFR was evaluated from (51)Cr-EDTA plasma clearance using blood samples taken at 2, 3 and 4 h. The slope-intercept GFR was corrected for body surface area (BSA) using the Haycock formula and for the fast exponential using the Brochner-Mortensen equation. The relationship between age, gender and GFR was examined using best-fit curve analysis. Nonlinear relationships with age were explored using fractional polynomials. RESULTS: There was no gender difference in BSA-corrected GFR over five decades of age (P = 0.40). However, female donors with a body mass index >30 kg/m(2) had a statistically significantly lower GFR than nonobese women (P < 0.01). The best-fit relationship between age and GFR was nonlinear and described using a fractional polynomial model of degree 1 (GFR = 103.9-0.0061 × Age(2) mL/min/1.73 m(2)) with a root mean standard error of 12.9 mL/min/1.73 m(2). The residual variance for this model was significantly smaller than for the best-fit linear model (P = 0.006). CONCLUSIONS: GFR measurements in prospective living kidney donors are best corrected for age using a nonlinear relationship.

Education and training in NOTES: a systematic review.

INTRODUCTION: Since the first published work on natural orifice translumenal endoscopic surgery (NOTES) a decade ago, progress has been made in the domain of education and training, although questions posed by the original White Paper remain. This article aims to review the current status of education and training in NOTES. METHODS: A review of the literature was conducted to evaluate the following: (1) What are the current training methods/modalities used for NOTES; what is the level of evidence to support their use? (2) How has NOTES clinical training been quantified; what is the evidence relating to performance of different NOTES operators? (3) What clinical NOTES training programs have been established and what are the wider training needs? RESULTS: A total of 25 studies were included: 11 nonanimal studies, 8 animal studies, and 6 descriptions of education programs. Several animal and simulator models demonstrated construct validity, but no study showed human predictive validity. Logarithmic learning curves in animal models demonstrate 10 to 15 cases achieving a proficiency level. Current trends are that gastroenterologists prefer it for diagnostic and basic procedures, whereas surgeons prefer it for complex therapeutic cases. CONCLUSION: The development of a new specialty is intriguing but currently unviable. Training programs have been initiated, but information is limited; the common theme is surgeons receiving endoscopic training. Despite the research done, our knowledge of training and educating in NOTES procedures is limited, preventing a meta-analysis or formal review from being performed. Further research is needed to integrate NOTES into routine clinical procedure.

Learning basic laparoscopic skills: a randomized controlled study comparing box trainer, virtual reality simulator, and mental training.

OBJECTIVES: The objectives of this study were (1) to compare different methods of learning basic laparoscopic skills using box trainer (BT), virtual reality simulator (VRS) and mental training (MT); and (2) to determine the most effective method of learning laparoscopic skills. DESIGN: Randomized controlled trial. SETTING: King's College, London. METHODS: 41 medical students were included in the study. After randomization, they were divided into 5 groups. Group 1 was the control group without training; group 2 was box trained; group 3 was also box trained with an additional practice session; group 4 was VRS trained; and group 5 was solely mentally trained. The task was to cut out a circle marked on a stretchable material. All groups were assessed after 1 week on both BT and VRS. Four main parameters were assessed, namely time, precision, accuracy, and performance. RESULTS: Time: On BT assessment, the box-trained group with additional practice group 3 was the fastest, and the mental-trained group 5 was the slowest. On VRS assessment, the time difference between group 3 and the control group 1 was statistically significant. Precision: On BT assessment, the box-trained groups 2 and 3 scored high, and mental trained were low on precision. On VRS assessment, the VRS-trained group ranked at the top, and the MT group was at the bottom on precision. Accuracy: On BT assessment, the box-trained group 3 was best and the mental-trained group was last. On VRS assessment, the VRS-trained group 4 scored high closely followed by box-trained groups 2 and 3. Performance: On BT assessment, the box-trained group 3 ranked above all the other groups, and the mental-trained group ranked last. On VRS assessment, the VRS group 4 scored best, followed closely by box-trained groups 2 and 3. CONCLUSIONS: The skills learned on box training were reproducible on both VRS and BT. However, not all the skills learned on VRS were transferable to BT. Furthermore, VRS was found to be a reliable and the most convenient method of assessment. MT alone cannot replace conventional training.

Instigating change: trainee doctors' perspective.

In the 21st century, the core skills of trainee doctors are evolving as clinicians, leaders and innovators. Leadership skills are an essential tool for all doctors and need to be an integral part of their training and learning as set out in the General Medical Council's Good Medical Practice. It is essential to develop these skills at an early stage and continually improve them. A group of junior doctors participated in a pilot programme for leadership with the aim of executing a quality improvement (QI) project. This article describes our experiences of both the course itself and the project undertaken by our group. As part of the process of implementing change, we faced a number of challenges which contributed to our learning. These have been explored as well as potential ways to overcome them to enable the swift and smooth development of future QI projects. Using an example of a QI project looking at handover, this article demonstrates how a trainee doctor can implement their project for both professional and institutional improvement.