When less is more: Updates in active surveillance and watchful waiting in the management of prostate cancer.

BACKGROUND: Prostate cancer is the second most common cancer among men globally. A range of management options are available for prostate cancer, including surgery, radiation therapy, hormone therapy, chemotherapy, or surveillance. Conservative strategies include active surveillance and watchful waiting, which differ in their intent. OBJECTIVE: We provide a targeted instructive management algorithm for improving understanding of conservative strategies in prostate cancer. DISCUSSION: Active surveillance involves close monitoring with curative intent when there is evidence of disease progression. In contrast, watchful waiting is palliative in intent and focuses on delaying treatment until symptoms or complications develop. Conservative approaches have demonstrated similar long-term oncological outcomes to radical treatment, while reducing harm from overtreatment, and maintaining quality of life by avoiding potential side effects such as urinary incontinence and erectile dysfunction. The decision to employ a conservative approach is determined by both patient and disease factors. Conservative management strategies play a vital role in the management of prostate cancer.

Evolution of hormonal therapy for prostate cancer.

BACKGROUND: Prostate cancer (PCa) is the most common malignancy after skin cancer in men in Australia. Its management varies according to tumour stage. Due to the significant dependence on androgen receptor signalling, agents that interfere with this pathway (most commonly medical castration in the form of androgen deprivation therapy [ADT]) are the mainstay treatment of advanced disease. OBJECTIVE: This review provides a contemporary update on ADT, with further discussion of emerging novel therapies for primary care. DISCUSSION: ADT is currently indicated for the treatment of metastatic prostate cancer, disease recurrence following attempted local curative therapy, as well as combined use with radiotherapy for intermediate/high-risk disease. There has been rapid development of new pharmaceuticals targeting the androgen receptor. These are reviewed historically with an emphasis placed on emerging therapies, their common side effects, and how to manage them in the general practice setting.

Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42].

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

Diagnostic Value of Urine Cytology in Pharmacologically Forced Diuresis for Upper Tract Urothelial Carcinoma Diagnosis and Follow-Up.

We performed a urine cytology analysis of a pharmacologically induced diuresis for the diagnosis of upper tract urothelial carcinoma. To evaluate the diagnostic value of cytology of pharmacologically forced diuresis, an initial cohort of 77 consecutive patients with primary upper tract urothelial carcinoma treated via radical surgery was enrolled. To evaluate pharmacologically forced diuresis cytology as a follow-up procedure, a second cohort of 1250 patients who underwent a radical cystectomy for bladder cancer was selected. In the first cohort, the sensitivity of cytology of pharmacologically forced diuresis in patients with invasive, high-grade, low-grade, and concomitant carcinoma in situ was 8%, 9%, 0%, and 14%, respectively. In the second cohort, cytology of pharmacologically forced diuresis was positive in 30/689 (4.3%) patients, in whom upper urinary tract recurrence was present in 21/30 (70%) of cases, and urethral recurrence was present in 8/30 (26%) of cases. As a follow-up tool, cytology of pharmacologically forced diuresis showed a sensitivity, specificity, and positive and negative predictive values of 60%, 99%, 70%, and 98%, respectively. Overall, as a diagnostic tool, the sensitivity of cytology of pharmacologically forced diuresis is slightly better in patients with invasive upper tract urothelial carcinoma and concomitant carcinoma in situ. As a follow-up method, positive cytology of pharmacologically forced diuresis is strongly related to cancer recurrence and can reveal urethral recurrence. Cytology of pharmacologically forced diuresis might be useful in cases with contraindications for imaging or when achieving endoscopic access to the upper urinary tract is difficult.

Oncological outcomes after attempted nerve-sparing radical prostatectomy (NSRP) in patients with high-risk prostate cancer are comparable to standard non-NSRP: a longitudinal long-term propensity-matched single-centre study.

OBJECTIVE: To assess the long-term safety of nerve-sparing radical prostatectomy (NSRP) in men with high-risk prostate cancer (PCa) by comparing survival outcomes, disease recurrence, the need for additional therapy, and perioperative outcomes of patients undergoing NSRP to those having non-NSRP. PATIENTS AND METHODS: We included consecutive patients at a single, academic centre who underwent open RP for high-risk PCa, defined as preoperative prostate-specific antigen level of > 20 ng/mL and/or postoperative International Society of Urological Pathology Grade Group 4 or 5 (i.e., Gleason score ≥ 8) and/or ≥pT3 and/or pN1 assessing the RP and lymph node specimen. We calculated a propensity score and used inverse probability of treatment weighting to match baseline characteristics of patients with high-risk PCa who underwent NSRP vs non-NSRP. We analysed oncological outcome as time-to-event and calculated hazard ratios (HRs). RESULTS: A total of 726 patients were included in this analysis of which 84% (n = 609) underwent NSRP. There was no evidence for the positive surgical margin rate being different between the NSRP and non-NSRP groups (47% vs 49%, P = 0.64). Likewise, there was no evidence for the need for postoperative radiotherapy being different in men who underwent NSRP from those who underwent non-NSRP (HR 0.78, 95% confidence interval [CI] 0.53-1.15). NSRP did not impact the risk of any recurrence (HR 0.99, 95% CI 0.73-1.34, P = 0.09) and there was no evidence for survival being different in men who underwent NSRP to those who underwent non-NSRP (HR 0.65, 95% CI 0.39-1.08). There was also no evidence for the cancer-specific survival (HR 0.56, 95% CI 0.29-1.11) or progression-free survival (HR 0.99, 95% CI 0.73-1.34) being different between the groups. CONCLUSION: In patients with high-risk PCa, NSRP can be attempted without compromising long-term oncological outcomes provided a comprehensive assessment of objective (e.g., T Stage) and subjective (e.g., intraoperative appraisal of tissue planes) criteria are conducted.

Cost Effectiveness of Systemic Treatment Intensification for Metastatic Hormone-sensitive Prostate Cancer: Is Triplet Therapy Cost Effective?

BACKGROUND AND OBJECTIVE: There has been a shift toward systemic treatment intensification for men with metastatic hormone-sensitive prostate cancer (mHSPC). Recent trials have demonstrated the efficacy of triplet therapy with an androgen receptor signalling inhibitor (ARSI), docetaxel, and androgen deprivation therapy (ADT). However, ARSI treatment is expensive. The objective was to determine the cost effectiveness of current treatments strategies for men with mHSPC. METHODS: We developed a Markov state-transition model to simulate outcomes for men with newly diagnosed mHSPC. For the simulation, patients were entered in the model in the mHSPC disease state before progressing to castration-resistant disease and finally dying from prostate cancer. Costs were calculated from a USA health sector perspective in 2022 US dollars. Deterministic and probabilistic sensitivity analyses were conducted to account for uncertainty in the parameter estimates. We also performed scenario analyses for costs in the UK and Australian health sectors. KEY FINDINGS AND LIMITATIONS: Treatment intensification with doublet and triplet therapy resulted in an improvement in quality-adjusted survival for all strategies in comparison to ADT monotherapy. However, only docetaxel doublet therapy was cost effective at standard thresholds, with an incremental cost-effectiveness ratio of $13 647. The cost of ARSIs needed to be discounted by 47-70% before they were cost effective. Only medication costs impacted the model results. If the generic price for abiraterone acetate is used, then triplet therapy with abiraterone is the best-value option. Similar results were obtained for analyses for the UK and Australian health sectors. CONCLUSIONS AND CLINICAL IMPLICATIONS: Treatment intensification with ARSIs in men with mHSPC results in better quality-adjusted survival but is not cost effective according to standard thresholds. The costs of these medications would need to be heavily discounted before they are cost effective. The cost of generic ARSIs, once available, would render these strategies cost effective. PATIENT SUMMARY: This report examines whether increasing the number of systemic drugs used to treat a patient's metastatic hormone-sensitive prostate cancer is cost effective for the health care system. We found that the additional cost of triplet therapy does not justify the increase in patient benefit.

Functional Impact of Neuro-Vascular Bundle Preservation in High Risk Prostate Cancer without Compromising Oncological Outcomes: A Propensity-Modelled Analysis.

Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n = 158) underwent non-NSRP and 39% (n = 516) and 50% (n = 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p = 0.09), and there was no difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39-1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29-1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.

Primary follicular lymphoma of an extraordinarily large prostate: A case report and review of the literature.

Primary follicular lymphoma of the prostate is rare. This case report and literature review literature describes a 74-year old male patient who presented with worsening urinary symptoms, and imaging showing prostatomegaly compressing and displacing the rectum. He ultimately underwent a Millen retropubic prostatectomy for a prostate of 692 cc. The histology and immunohistochemistry confirmed the diagnosis as follicular lymphoma. His lymphoma underwent high-grade transformation with leptomeningeal involvement.

RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned.

Background: The surgical difficulty of partial nephrectomy (PN) varies depending on the operative approach. Existing nephrometry classifications for assessment of surgical difficulty are not specific to the robotic approach. Objective: To develop an international robotic-specific classification of renal masses for preoperative assessment of surgical difficulty of robotic PN. Design setting and participants: The RPN classification (Radius, Position of tumour, iNvasion of renal sinus) considers three parameters: tumour size, tumour position, and invasion of the renal sinus. In an international survey, 45 experienced robotic surgeons independently reviewed de-identified computed tomography images of 144 patients with renal tumours to assess surgical difficulty of robot-assisted PN using a 10-point Likert scale. A separate data set of 248 patients was used for external validation. Outcome measurements and statistical analysis: Multiple linear regression was conducted and a risk score was developed after rounding the regression coefficients. The RPN classification was correlated with the surgical difficulty score derived from the international survey. External validation was performed using a retrospective cohort of 248 patients. RPN classification was also compared with the RENAL (Radius; Exophytic/endophytic; Nearness; Anterior/posterior; Location), PADUA (Preoperative Aspects and Dimensions Used for Anatomic), and SPARE (Simplified PADUA REnal) scoring systems. Results and limitation: The median tumour size was 38 mm (interquartile range 27-49). The majority (81%) of renal tumours were peripheral, followed by hilar (12%) and central (7.6%) locations. Noninvasive and semi-invasive tumours accounted for 37% each, and 26% of the tumours were invasive. The mean surgical difficulty score was 5.2 (standard deviation 1.9). Linear regression analysis indicated that the RPN classification correlated very well with the surgical difficulty score (R2 = 0.80). The R2 values for the other scoring systems were: 0.66 for RENAL, 0.75 for PADUA, and 0.70 for SPARE. In an external validation cohort, the performance of all four classification systems in predicting perioperative outcomes was similar, with low R2 values. Conclusions: The proposed RPN classification is the first nephrometry system to assess the surgical difficulty of renal masses for which robot-assisted PN is planned, and is a useful tool to assist in surgical planning, training and data reporting. Patient summary: We describe a simple classification system to help urologists in preoperative assessment of the difficulty of robotic surgery for partial kidney removal for kidney tumours.

Same day discharge for robot-assisted radical prostatectomy: a prospective cohort study documenting an Australian approach.

BACKGROUND: The introduction of robotic surgical systems has significantly impacted urological surgery, arguably more so than other surgical disciplines. The focus of our study was length of hospital stay - patients have traditionally been discharged day 1 post-robot-assisted radical prostatectomy (RARP), however, during the ongoing COVID-19 pandemic and consequential resource limitations, our centre has facilitated a cohort of same-day discharges with initial success. METHODS: We conducted a prospective tertiary single-centre cohort study of a series of all patients (n = 28) - undergoing RARP between January and April 2021. All patients were considered for a day zero discharge pathway which consisted of strict inclusion criteria. At follow-up, each patient's perspective on their experience was assessed using a validated post-operative satisfaction questionnaire. Data were reviewed retrospectively for all those undergoing RARP over the study period, with day zero patients compared to overnight patients. RESULTS: Overall, 28 patients 20 (71%) fulfilled the objective criteria for day zero discharge. Eleven patients (55%) agreed pre-operatively to day zero discharge and all were successfully discharged on the same day as their procedure. There was no statistically significant difference in age, BMI, ASA, Charlson score or disease volume. All patients indicated a high level of satisfaction with their procedure. Median time from completion of surgery to discharge was 426 min (7.1 h) in the day zero discharge cohort. CONCLUSION: Day zero discharge for RARP appears to deliver high satisfaction, oncological and safety outcomes. Therefore, our study demonstrates early success with unsupported same-day discharge in carefully selected and pre-counselled patients.

A Systematic Review of Intra- and Postoperative Complication Reporting and Grading in Urological Surgery: Understanding the Pitfalls and a Path Forward.

CONTEXT: Surgical outcomes and patient morbidity are often surrogate markers of health care quality and efficiency. These parameters can only be used with confidence if the reporting and grading of intra- and postoperative complications are reliable and reproducible. Without uniformity and regulation, the risk of under-reporting, and thus significant underestimation of the burden of intra- and postoperative morbidity, is high and should be of great concern to the international surgical community. OBJECTIVE: To assess the quality and utility of currently available reporting and classification systems for intra- and postoperative complications, recognise their advantages and pitfalls, discuss the overall implications of these systems for urological surgery, and identify potential solutions for future reporting and classification systems. EVIDENCE ACQUISITION: A comprehensive search was performed using multiple reputable databases and trial registries up to October 25, 2022. Only studies that adhered to predefined inclusion criteria were included. Study selection and data extraction were independently performed by two review authors. The review was performed according to strict methodological guidelines in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. EVIDENCE SYNTHESIS: A total of 13 papers highlighting 13 various complication systems were critically assessed in this review. All studies proposed an intra- or postoperative complication reporting or grading system that was surgically related. At present, there is no single instrument in clinical practice to account for all relevant complication data. Six of the 13 studies were clinically validated (46%) and only three studies were urology-focused (23%). Meta-analysis was not possible. CONCLUSIONS: Current individual complication tools are flawed, so there is a need for a novel, all-inclusive, specialty-specific reporting and classification system for intra- and postoperative complications. If successfully validated and integrated worldwide, such an instrument would have the potential to play a significant role in reshaping efficiency in health care systems and improving surgical and patient quality of care. PATIENT SUMMARY: Current tools for reporting and classifying complications during and after surgery underestimate how burdensome such complications can be for patients. We summarise the reporting and classification tools currently available, discuss their advantages and drawbacks, and propose potential solutions for future systems. Our review can help in better understanding the changes required for future tools and how to improve overall surgical outcomes for patients.

Emergence of triplet therapy for metastatic castration-sensitive prostate cancer: An updated systematic review and network meta-analysis.

INTRODUCTION: There have been a growing number of treatment options available for men with metastatic castration-sensitive prostate cancer. Not only have newer agents entered the clinical landscape, there is a trend toward treatment intensification by combining multiple agents simultaneously. We aim to assess the best contemporary treatment option for men with mCSPC. MATERIALS AND METHODS: We perform an updated systematic review and network meta-analysis of randomized control trials that evaluated systemic therapies in men with castration-sensitive prostate cancer. We searched multiple databases up to April 2022. We included all randomized trials assessing the effect of systemic agents. We performed subgroup analyses based on disease volume and timing of presentation. Statistical analysis was performed with Bayesian methods. RESULTS: We found 10 eligible trials with 10,065 patients who were included in this analysis. Triplet therapy with darolutamide or abiraterone with docetaxel and ADT improved overall survival. In the sensitivity analysis, the respective hazard ratios for triplet therapy was HR 0.70 (95%CI 0.61-0.80) compared to docetaxel+ADT and 0.77 (95%CI 0.65-0.91) compared to androgen receptor pathway inhibitors+ADT combinations. It was estimated that there was 96% chance that one of the triplet therapy combinations were the best treatment option from an OS perspective. Triplet therapy also improved progression-free survival. These benefits were pronounced in men with high-volume disease burden and those with de novo metastatic disease. CONCLUSION: The finding suggest that triplet therapy is likely the most efficacious available option in men with metastatic, castration-sensitive prostate cancer, especially in those with high-volume disease burden.

Lymphovascular Invasion at the Time of Radical Prostatectomy Adversely Impacts Oncological Outcomes.

Lymphovascular invasion, whereby tumour cells or cell clusters are identified in the lumen of lymphatic or blood vessels, is thought to be an essential step in disease dissemination. It has been established as an independent negative prognostic indicator in a range of cancers. We therefore aimed to assess the impact of lymphovascular invasion at the time of prostatectomy on oncological outcomes. We performed a multicentre, retrospective cohort study of 3495 men who underwent radical prostatectomy for localised prostate cancer. Only men with negative preoperative staging were included. We assessed the relationship between lymphovascular invasion and adverse pathological features using multivariable logistic regression models. Kaplan-Meier curves and Cox proportional hazard models were created to evaluate the impact of lymphovascular invasion on oncological outcomes. Lymphovascular invasion was identified in 19% (n = 653) of men undergoing prostatectomy. There was an increased incidence of lymphovascular invasion-positive disease in men with high International Society of Urological Pathology (ISUP) grade and non-organ-confined disease (p < 0.01). The presence of lymphovascular invasion significantly increased the likelihood of pathological node-positive disease on multivariable logistic regression analysis (OR 15, 95%CI 9.7-23.6). The presence of lymphovascular invasion at radical prostatectomy significantly increased the risk of biochemical recurrence (HR 2.0, 95%CI 1.6-2.4). Furthermore, lymphovascular invasion significantly increased the risk of metastasis in the whole cohort (HR 2.2, 95%CI 1.6-3.0). The same relationship was seen across D'Amico risk groups. The presence of lymphovascular invasion at the time of radical prostatectomy is associated with aggressive prostate cancer disease features and is an indicator of poor oncological prognosis.

Effect of local steroids on urethral strictures: A systematic review and meta-analysis.

PURPOSE: Urethral stricture disease is common and has high associated morbidity and impact on quality-of-life. This systematic review and meta-analysis aims to summarise current evidence on the efficacy of local urethral steroids post-direct vision internal urethrotomy (DVIU) for the treatment of urethral strictures in males. MATERIALS AND METHODS: A comprehensive search was performed using reputable databases and registries, up to 22 February 2022. Only randomised control trials in which participants were randomised to DVIU plus local urethral steroids versus DVIU only were included. Statistical analyses were performed using a random-effects model. Quality of evidence was rated according to the GRADE approach. RESULTS: The search identified seven studies in which 365 participants were randomised to DVIU plus local urethral steroids versus DVIU only. The application of local steroids appeared to reduce recurrence rates (risk ratio, 0.67; 95% confidence interval [CI], 0.49-0.90) and time-to-recurrence (hazard ratio, 0.58; 95% CI, 0.39-0.85). Qmax also improved following steroid application (mean difference, 0.82; 95% CI, -1.02-2.66); however, this was not statistically significant. No heterogeneity was identified between included studies for all outcomes. The certainty of evidence was downgraded due to study limitations with a small sample size and unclear risk-of-bias related to insufficient trial information. CONCLUSIONS: Compared to DVIU alone, adjuvant steroids applied to the urethra may reduce risk of recurrence and time-to-recurrence. These findings were statistically significant and likely also clinically significant given low associated costs and risk. However, more robust randomised trials are necessary to enhance the validity of these outcomes.

Protocol for CAMUS Delphi Study: A Consensus on Comprehensive Reporting and Grading of Complications After Urological Surgery.

BACKGROUND: Reproducible assessment of postoperative complications is essential for reliable evaluation of quality of care to enable comparison between healthcare centres and ensure transparent patient counselling. Currently, significant discrepancies exist in complication reporting and grading due to heterogeneous definitions and methodologies. OBJECTIVE: To develop a standardised and reproducible assessment of perioperative complications and overall associated morbidity, to allow for the construction of a uniform language for complication reporting and grading. DESIGN, SETTING, AND PARTICIPANTS: The 12-part REDCap-based Delphi survey was developed in conjunction with methodologist review and experienced urologist opinion. International urologists, anaesthetists, and intensive care unit specialists will be included. A minimum sample size of 750 participants (500 urologists and 250 critical care specialities) is targeted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The survey assesses participant demographics, opinion on complication reporting and the proposed Complications After Major & Minor Urological Surgery (CAMUS) reporting recommendations, grading of intervention events using the existing Clavien-Dindo classification and the proposed CAMUS classification, and rating of various clinical scenarios. Consensus will be defined as ≥75% majority agreement. If consensus is not reached, then subsequent Delphi rounds will be performed under steering committee guidance. RESULTS AND LIMITATIONS: Twenty-one participants completed the draft survey. The median survey completion time was 128 min (interquartile range 88-135). The survey revealed that 90% of participants believe that the current complication classification systems are useful but inaccurate, while 100% of participants believe that there is a universal demand for reporting consensus. Several amendments were made following feedback. Limitations include complexity of the proposed supplemental grades and time to completion of the survey. CONCLUSIONS: To ensure comprehensive and comparable complication reporting and grading across centres worldwide, a conclusive uniform language for complication reporting must be created. We intend to address shortcomings of the current complication reporting and classification systems with a new CAMUS classification system developed through multidisciplinary expert consensus obtained through a Delphi survey. Ultimately, standardisation of urological complication reporting and grading may improve patient counselling and quality of care. PATIENT SUMMARY: The reporting and grading of operative complications that occur during or after an operation and associated costs provide a means to stratify quality of patient care. Current complication reporting and classification systems are not standardised and somewhat inaccurate, and thus significantly underestimate patient morbidity and surgical risk. This Delphi survey will provide the basis for the creation of a uniform complication reporting and grading system. Our new system may allow improved reporting and grading between centres, and ultimately improve patient counselling and care.

Selective Serotonin Re-Uptake Inhibitors for Premature Ejaculation in Adult Men: A Cochrane Systematic Review.

PURPOSE: Selective serotonin re-uptake inhibitors (SSRIs) are frequently used to treat premature ejaculation (PE) in men. We performed a Cochrane review to assess the efficacy of SSRI treatment for PE. MATERIALS AND METHODS: We extensively searched a range of databases up to May 2020 and only included randomized controlled trials. RESULTS: A total of 31 studies with 8,254 men were included in this analysis. We found that SSRI treatment probably improves self-perceived PE symptoms (defined as a rating of 'better' or 'much better'; risk ratio [RR], 1.92; 95% confidence interval [CI], 1.66-2.23; moderate-certainty evidence) and satisfaction with intercourse (defined as a rating of 'good' or 'very good'; RR, 1.63; 95% CI, 1.42-1.87; moderate-certainty evidence) compared to placebo. Furthermore, SSRI treatment likely improve participants' self-perceived control over ejaculation (defined as rating of 'good' or 'very good'; RR, 2.29; 95% CI, 1.72-3.05; moderate-certainty evidence) and probably lessens distress (defined as rating of 'a little bit' or 'not at all') about PE (RR, 1.54; 95% CI, 1.26-1.88; moderate-certainty evidence). SSRI treatment may increase IELT compared to placebo (mean difference, 3.09 minutes higher; 95% CI, 1.94 higher to 4.25 higher; low-certainty evidence). However, SSRIs may increase treatment cessations due to adverse events compared to placebo (RR, 3.80; 95% CI, 2.61-5.51; low-certainty evidence). CONCLUSIONS: SSRI treatment for PE appears to substantially improve a number of outcomes of direct patient importance such as symptom improvement, satisfaction with intercourse and perceived control over ejaculation when compared to placebo.

There is a Need for a Universal Language in the Reporting and Grading of Complication and Intervention Events to Ensure Comparability and Improvement of Surgical Care.

To enhance the clarity and quality of complication reporting and grading for clinicians and patients, the CAMUS-Collaboration aims to develop the following: (1) a data dictionary; (2) parameters required for reporting; (3) risk-based reporting; (4) nursing and patient opinions; and (5) prospective reporting and grading of short- and long-term complications.