Barriers and enablers of active surveillance for prostate cancer: a qualitive study of clinicians.

OBJECTIVES: To identify and explore barriers to, and enablers of, active surveillance (AS) in men with low-risk prostate cancer (LRPCa), as perceived by PCa clinicians. PATIENTS AND METHODS: Urologists and radiation oncologists in Australia and New Zealand were purposively sampled for a cross-section on gender and practice setting (metropolitan/regional; public/private). Using a grounded theory approach, semi-structed interviews were conducted with participants. Interviews were coded independently by two researchers using open, axial, and selective coding. A constant comparative approach was used to analyse data as it was collected. Thematic saturation was reached after 18 interviews, and a detailed model of barriers to, and enablers of, AS for LRPCa, as perceived by clinicians was developed. RESULTS: A model explaining what affects clinician decision making regarding AS in LRPCa emerged. It was underpinned by three broad themes: (i) clinician perception of patients' barriers and enablers; (ii) clinician perception of their own barriers and enablers; and (iii) engagement with healthcare team and resource availability. CONCLUSIONS: Clinicians unanimously agree that AS is an evidence-based approach for managing LRPCa. Despite this many men do not undergo AS for LRPCa, which is due to the interplay of patient and clinician factors, and their interaction with the wider healthcare system. This study identifies strategies to mitigate barriers and enhance enablers, which could increase access to AS by patients with LRPCa.

Modern Active Surveillance in Prostate Cancer: A Narrative Review.

The use of PSA screening has led to downstaging and downgrading of prostate cancer at diagnosis, increasing detection of indolent disease. Active surveillance aims to reduce over-treatment by delaying or avoiding radical treatment and its associated morbidity. However, there is not a consensus on the selection criteria and monitoring schedules that should be used. This article aims to summarize the evidence supporting the safety of active surveillance, the current selection criteria recommended and in use, the incidence of active surveillance, barriers existing to its uptake and future developments in patient selection.

Protocol for mixed-method systematic review of urology in medical school education.

INTRODUCTION: Throughout clinical practice, most doctors will encounter patients with urological conditions. Inclusion of urological topics within medical school curriculums is important to allow doctors to effectively diagnose and manage these conditions, independently and with support from urologists. Awareness of urological education interventions and their effectiveness is essential for improving the quality and outcomes of medical student education. No systematic review of medical school education interventions on urological topics has previously been conducted. This mixed-method systematic review will assess the effectiveness of medical school education interventions on urological topics. METHODS AND ANALYSIS: This mixed-methods systematic review will include qualitative and quantitative studies involving education interventions or practices regarding urological topics conducted within a medical school curriculum. Studies regarding other curriculums including premedical education, junior doctor prevocational education or vocational urological training will be excluded. A search of CINAHL, ERIC, EMBASE, MEDLINE will be conducted for studies published since the year 2001. Dual independent screening of titles and abstracts prior to full text review will be undertaken for all identified results during the initial searches. Any disagreement will be settled by a third reviewer. A convergent segregated approach will be used to synthesise qualitative and quantitative data independently, with the results juxtaposed to identify shared and divergent findings between study types. ETHICS AND DISSEMINATION: No ethical approval was required for this review. Findings from this review will be disseminated via publication, reports and conference presentations.

Bladder cancer in Aboriginal and Torres Strait Islander people living in Australia: a scoping review protocol.

INTRODUCTION: Bladder cancer is the third most common urological malignancy affecting Australians, with key modifiable risk factors. Aboriginal and Torres Strait Islander people suffer from a higher prevalence of cancer-modifiable risk factors, are diagnosed with bladder cancer at a younger age, and have poorer survival rates compared with the general population. A comprehensive overview of the state of current knowledge on bladder cancer in this population is required. METHODS AND ANALYSIS: A search of MEDLINE, CINAHL, EMBASE and Web of Science databases, along with appropriate grey literature sources will be conducted between the 1 April 2022 and 30 April 2022. The reference lists of all included studies will be reviewed for additional appropriate sources. The national bladder cancer dataset compiled by the Australian Institute of Health and Welfare will also be included as a source. All relevant sources meeting inclusion criteria, published in English, from inception onwards will be included. Dual independent screening of titles and abstracts prior to full-text review will be undertaken for all identified results during the initial searches. Preliminary findings will be reviewed with stakeholders, to seek culturally appropriate feedback on the implications of the results. Results will be reported in tabular form, accompanied by a narrative synthesis with comparisons to the wider bladder cancer population. ETHICS AND DISSEMINATION: Ethics review will not be required, as only publicly available data will be analysed. Findings from the scoping review will be published in a peer-reviewed journal and presented at scientific meetings to stakeholders.

Performance of Ga-68 PSMA PET/CT for diagnosis and grading of local prostate cancer.

BACKGROUND: We aimed to evaluate the utility of prostate-specific membrane antigen (PSMA) PET/CT for the detection of local disease within the prostate. METHODS: This is a retrospective review of a single-center experience evaluating intraprostatic detection rates compared with final histopathology in a radical prostatectomy (RP) population. Seventy-two patients had PSMA PET/CT scan performed as part of their primary staging. Intraprostatic PSMA PET/CT avidity was assessed. PSMA PET/CT uptake was retrospectively correlated with patient characteristics including final histopathology, MRI Prostate Imaging Reporting and Data System (PI-RADS) score, clinical tumor stage, prostate-specific antigen (PSA) level, and patient age. RESULTS: The sensitivity of PSMA PET/CT for the detection of RP-confirmed prostate cancer was 81.2%. Much higher sensitivity was found within certain subpopulations. The patient characteristics that most strongly correlated with focal intraprostatic PSMA PET/CT uptake were patient age (Kendall's tau coefficient τb = 0.24, p < 0.05) and clinical T stage (τb = 0.21, p < 0.05).The International Society of Urological Pathology (ISUP) grade group from final RP was predicted by standardized uptake value (SUVmax) and to a lesser extent PSA and the maximal dimension of PET-avid lesions. SUVmax monotonically increased with ISUP grade group. If SUVmax was above 10 g/mL, the final RP histopathology had a relative risk of 2.3 (95% CI 1.3-4.1) of being ISUP grade group 5. CONCLUSION: This trial provides early evidence that PSMA PET/CT assists in the grading of prostate cancer and suggests that the imaging modality is particularly accurate in subpopulations including the elderly and those with palpable disease.

Evaluating the Effectiveness of an Online Journal Club: Experience from the International Urology Journal Club.

BACKGROUND: The International Urology Journal Club attracts global participation; however, its effectiveness as an educational resource is undetermined. OBJECTIVE: To evaluate the effectiveness of the international Twitter-based urology journal club (#urojc) using Kirkpatrick's evaluation model and to quantify the development of #urojc into a robust educational platform. DESIGN, SETTING, AND PARTICIPANTS: A 13-item survey was sent to 3127 followers of #urojc. Twitter metrics including number of users, tweets, and impressions during 24 mo of operation were obtained via a third-party service "Symplur." Tweets were qualitatively analyzed to assess for relevance. Kirkpatrick's four-level evaluation model (reaction, learning, behavior, and results) was applied to analyze impact and effectiveness. RESULTS AND LIMITATIONS: Survey participation rate was 48% (after accounting for spam and inactive accounts). The reaction (Kirkpatrick level 1) to #urojc was overwhelmingly positive. Consultant urologists were the most active participants while trainees reported highest educational value. As much as 45% of junior consultant urologists and trainees reported a change in practice as a result of #urojc participation. The number of unique users of #urojc almost doubled from yr 1 to 2. The number of tweets per month and author participation increased from yr 1 to 2. The proportion of content-relevant tweets remained stably high at approximately 60%. This study was unable to document any impact on knowledge, behavior, or outcomes of #urojc (Kirkpatrick levels 2-4). Silent observers who do not follow #urojc were not captured. CONCLUSIONS: To our knowledge, this is the first time Kirkpatrick's evaluation model has been applied to a journal club. The reaction to #urojc among survey responders is positive with change in practice also reported. It appears that #urojc achieves level 1 of Kirkpatrick's evaluation model. Further investigation is required for levels 2-4. Twitter-based journal clubs draw robust global participation and have inspired journal clubs in other specialties. PATIENT SUMMARY: This report highlights the importance of the International Urology Journal Club as a potential educational resource of consultant urologists and trainees alike. Global participation was a major advantage of this platform. This journal club has inspired other medical specialties to follow suit.

Quality and readability of online patient information on treatment for erectile dysfunction.

Objectives: To investigate the quality and readability of online patient information on treatment for erectile dysfunction using a Google search. Materials and methods: The results of a Google search for "erectile dysfunction treatment" were reviewed. Webpages that contained written information on erectile dysfunction except those containing scientific publications and paywall protected webpages were included in further analysis. Typographic and treatment information were recorded. Readability was assessed using the Fleisch-Kincaid grade level, the Gunning-Fog index, the Coleman-Liau index, and Simple Measure of Gobbledygook. Website quality was assessed using the DISCERN instrument, Journal of the American Medical Association (JAMA) benchmark criteria, and presence of Health on the net (HON) code certification. Website typography, discussed treatment types, readability scores, and quality measures were reported. Parametric and nonparametric statistical tests were used to compare the data as appropriate dependent on the normality of data. Results: Eighty-one webpages were included. Urologists and hospitals were the most common producers with 15 (18%) each. Seventy-four (91%) webpages contained specific information on treatment for erectile dysfunction and 15 (19%) contained advertisements. Seventeen (21%) webpages were HON code certified. The median DISCERN score was 35 (IQR 26.5-44) out of 80. The mean combined readability score was 12.32 (SD 1.91). The median JAMA benchmark score was 1 (IQR 1-2) out of 4. Google rank had a small negative correlation with DISCERN score (τ = -0.16, P = .036). HON code certified webpages had higher DISCERN scores (median of 44 [IQR 35-58.5] vs 32.5 [IQR 25.25-42.25], U = 832, Z = 6561, P < .001). A linear regression was used to predict DISCERN score based on meeting each JAMA benchmark criterion (F(2, 78) = 22.7, P < .001) R 2 = 0.368, P < .001. Within this model the effects of meeting attribution (ß = 11.09) and currency (ß = 8.79) criterion were significant. Conclusions: The quality of online information on treatment for erectile dysfunction is generally poor. However, easy to identify markers of quality like HON code certification, or meeting JAMA benchmark criterion for attribution and currency may help patients to navigate to better quality online information on treatment for erectile dysfunction. Webpages are written at senior high school level, above any recommendations for patient medical information. Health professionals should use validated instruments to assess the quality of online information on treatment for erectile dysfunction prior to publication to improve their utility for patients.

A Systematic Review and Meta-Analysis of Pelvic Drain Insertion After Robot-Assisted Radical Prostatectomy.

Purpose: To perform a systematic review and meta-analysis and to assess the clinical benefit of prophylactic pelvic drain (PD) placement after robot-assisted laparoscopic prostatectomy (RALP) with pelvic lymph node dissection (PLND) in patients with localized prostate cancer. Materials and Methods: An electronic search of databases, including Scopus, Medline, and EMbase, was conducted for articles that considered postoperative outcomes with PD placement and without PD (no drain) placement after RALP. The primary outcome was rate of symptomatic lymphocele (requiring intervention) and secondary outcomes were complications as described by the Clavien-Dindo classification system. Quality assessment was performed using the Modified Cochrane Risk of Bias Tool for Quality Assessment. Results: Six relevant articles comprising 1783 patients (PD = 1253; ND = 530) were included. Use of PD conferred no difference in symptomatic lymphocoele rate (risk difference 0.01; 95% confidence interval [CI] -0.007 to 0.027), with an overall incidence of 2.2% (95% CI 0.013-0.032). No difference in low-grade (I-II; risk difference 0.035, 95% CI -0.065 to 0.148) or high-grade (III-V; risk difference -0.003, 95% CI -0.05 to 0.044) complications was observed between PD and ND groups. Low-grade (I-II) complications were 11.8% (95% CI 0-0.42) and 7.3% (95% CI 0-0.26), with similar rates of high-grade (III-V) complications, being 4.1% (95% CI 0.008-0.084) and 4.3% (95% CI 0.007-0.067) for PD and ND groups, respectively. Conclusion: PD insertion after RALP with extended PLND did not confer significant benefits in prevention of symptomatic lymphocoele or postoperative complications. Based on these results, PD insertion may be safely omitted in uncomplicated cases after consideration of clinical factors.

Indirect Comparisons of Efficacy between Combination Approaches in Metastatic Hormone-sensitive Prostate Cancer: A Systematic Review and Network Meta-analysis.

CONTEXT: There have been substantial changes in the management of men with metastatic hormone-sensitive prostate cancer (mHSPC) over the past 5 yr, with upfront combination therapies replacing androgen-deprivation therapy (ADT) alone. A range of therapies have entered the space with no clear answer regarding their comparative efficacy. OBJECTIVE: To perform a systematic review and network meta-analysis to characterise the comparative efficacy of combination approaches in men with mHSPC. EVIDENCE ACQUISITION: We searched multiple databases and abstracts of major meetings up to June 2019 for randomised trials of patients receiving first-line therapy for metastatic disease, a combination of ADT and one (or more) of taxane-based chemotherapy, and androgen receptor-targeted therapies. The primary endpoint was overall survival (OS) and we evaluated progression-free survival as a secondary outcome. We performed subgroup analysis based on the volume of disease. EVIDENCE SYNTHESIS: We found seven trials that met our eligibility criteria using either docetaxel, abiraterone acetate, enzalutamide, or apalutamide in combination with ADT. All agents in combination with ADT were shown to be superior to ADT alone; enzalutamide + ADT had the lowest absolute hazard ratio compared with ADT only (hazards ratio 0.53, 95% confidence interval 0.37-0.75), and an estimated 76.9% probability that it is the preferred treatment to prolong OS compared with other combination treatments, or with ADT alone. Enzalutamide appeared to have better OS compared with docetaxel in men with low-volume disease, but there was no difference in other comparisons. CONCLUSIONS: Combination therapy with any of docetaxel, abiraterone acetate, enzalutamide, or apalutamide provides a significant OS benefit when compared with ADT alone. We did not identify significant differences in OS between different combination therapies. Subtle differences between these options provide clinicians considerable flexibility when selecting options for individual patients. PATIENT SUMMARY: Many men with metastatic, hormone-sensitive prostate cancer should be managed with upfront combination therapy instead of androgen-deprivation therapy alone. Clinicians may consider many factors during the decision-making process, and thus management should be tailored for patients individually.

Comparison between target magnetic resonance imaging (MRI) in-gantry and cognitively directed transperineal or transrectal-guided prostate biopsies for Prostate Imaging-Reporting and Data System (PI-RADS) 3-5 MRI lesions.

OBJECTIVE: To compare the detection rates of prostate cancer (PCa) in men with Prostate Imaging-Reporting and Data System (PI-RADS) 3-5 abnormalities on 3-Tesla multiparametric (mp) magnetic resonance imaging (MRI) using in-bore MRI-guided biopsy compared with cognitively directed transperineal (cTP) biopsy and transrectal ultrasonography (cTRUS) biopsy. METHODS: This was a retrospective single-centre study of consecutive men attending the private practice clinic of an experienced urologist performing MRI-guided biopsy and an experienced urologist performing cTP and cTRUS biopsy techniques for PI-RADS 3-5 lesions identified on 3-Tesla mpMRI. RESULTS: There were 595 target mpMRI lesions from 482 men with PI-RADS 3-5 regions of interest during 483 episodes of biopsy. The abnormal mpMRI target lesion was biopsied using the MRI-guided method for 298 biopsies, the cTP method for 248 biopsies and the cTRUS method for 49 biopsies. There were no significant differences in PCa detection among the three biopsy methods in PI-RADS 3 (48.9%, 40.0% and 44.4%, respectively), PI-RADS 4 (73.2%, 81.0% and 85.0%, respectively) or PI-RADS 5 (95.2, 92.0% and 95.0%, respectively) lesions, and there was no significant difference in detection of significant PCa among the biopsy methods in PI-RADS 3 (42.2%, 30.0% and 33.3%, respectively), PI-RADS 4 (66.8%, 66.0% and 80.0%, respectively) or PI-RADS 5 (90.5%, 89.8% and 90.0%, respectively) lesions. There were also no differences in PCa or significant PCa detection based on lesion location or size among the methods. CONCLUSION: We found no significant difference in the ability to detect PCa or significant PCa using targeted MRI-guided, cTP or cTRUS biopsy methods. Identification of an abnormal area on mpMRI appears to be more important in increasing the detection of PCa than the technique used to biopsy an MRI abnormality.

Transcaval ureter: a rare embryological anomaly causing obstructive uropathy.

A 21-year-old woman presented with a longstanding history of episodic right flank pain related to fluid consumption and recurrent urinary tract infections. On examination, there was right costovertebral angle tenderness. Renal tract ultrasound demonstrated hydronephrosis and CT urography confirmed transcaval ureter. The patient's clinical presentation was likely due to obstruction associated with the right ureter passing through the opening created by the duplicated segment of the inferior vena cava. While asymptomatic transcaval ureter can be managed conservatively, severe symptoms or complications of ureteric obstruction may require surgical treatment. In this case, treatment comprised a laparoscopic ureteroureterostomy with an end-to-end anastomosis between the proximal and distal sections of the right ureter. The patient's postoperative recovery was uneventful and she reported resolution of the flank pain during the one year of follow-up.

Bilateral adrenal haemorrhage associated with heparin-induced thrombocytopaenia during treatment of Fournier gangrene.

We present a case of bilateral adrenal haemorrhage (BAH) associated with heparin-induced thrombocytopaenia (HIT) in a 61-year-old man admitted to hospital for the treatment of Fournier's gangrene. He presented to hospital with scrotal swelling and fever, and developed spreading erythaema and a gangrenous scrotum. His scrotum was surgically debrided and intravenous broad-spectrum antibiotics were administered. Unfractionated heparin was given postoperatively for venous thromboembolism prophylaxis. The patient deteriorated clinically 8-11 days postoperatively with delirium, chest pain and severe hypertension followed by hypotension and thrombocytopaenia. Abdominal CT scan revealed bilateral adrenal haemorrhage. Antibodies to the heparin-platelet factor 4 complex were present. HIT-associated BAH was diagnosed and heparin was discontinued. Intravenous bivalirudin and hydrocortisone were started, with rapid improvement in clinical status. BAH is a rare complication of HIT and should be considered in the postoperative patient with unexplained clinical deterioration.