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.

A semi-automated software program to assess the impact of second reads in prostate MRI for equivocal lesions: results from a UK tertiary referral centre.

PURPOSE: To investigate the utility of a prostate magnetic resonance imaging (MRI) second read using a semi-automated software program in the one-stop clinic, where patients undergo multiparametric MRI, review and biopsy planning in one visit. We looked at concordance between readers for patients with equivocal scans and the possibility for biopsy deferral in this group. METHODS: We present data from 664 consecutive patients. Scans were reported by seven different expert genitourinary radiologists using dedicated software (MIM®) and a Likert scale. All scans were rescored by another expert genitourinary radiologist using a customised workflow for second reads that includes annotated biopsy contours for accurate visual targeting. The number of scans in which a biopsy could have been deferred using biopsy results and prostate specific antigen density was assessed. Gleason score ≥ 3 + 4 was considered clinically significant disease. Concordance between first and second reads for equivocal scans (Likert 3) was evaluated. RESULTS: A total of 209/664 (31%) patients scored Likert 3 on first read, 128 of which (61%) were concordant after second read. 103/209 (49%) of patients with Likert 3 scans were biopsied, with clinically significant disease in 31 (30%) cases. Considering Likert 3 scans that were both downgraded and biopsied using the workflow-generated biopsy contours, 25/103 (24%) biopsies could have been deferred. CONCLUSIONS: Implementing a semi-automated workflow for accurate lesion contouring and targeting biopsies is helpful during the one-stop clinic. We observed a reduction of indeterminate scans after second reading and almost a quarter of biopsies could have been deferred, reducing the potential biopsy-related side effects.

Contemporary patterns of local ablative therapies for prostate cancer at United States cancer centers: results from a national registry.

PURPOSE: To describe the national-level patterns of care for local ablative therapy among men with PCa and identify patient- and hospital-level factors associated with the receipt of these techniques. METHODS: We retrospectively interrogated the National Cancer Database (NCDB) for men with clinically localized PCa between 2010 and 2017. The main outcome was receipt of local tumor ablation with either cryo- or laser-ablation, and "other method of local tumor destruction including high-intensity focused ultrasound (HIFU)". Patient level, hospital level, and demographic variables were collected. Mixed effect logistic regression models were fitted to identify separately patient- and hospital-level predictors of receipt of local ablative therapy. RESULTS: Overall, 11,278 patients received ablative therapy, of whom 78.8% had cryotherapy, 15.6% had laser, and 5.7% had another method including HIFU. At the patient level, men with intermediate-risk PCa were more likely to be treated with local ablative therapy (OR 1.05; 95% CI 1.00-1.11; p = 0.05), as were men with Charlson Comorbidity Index > 1 (OR 1.36; 95% CI 1.29-1.43; p < 0.01), men between 71 and 80 years (OR 3.70; 95% CI 3.43-3.99; p < 0.01), men with Medicare insurance (OR 1.38; 95% 1.31-1.46; p < 0.01), and an income < $47,999 (OR 1.16; 95% CI 1.06-1.21; p < 0.01). At the hospital-level, local ablative therapy was less likely to be performed in academic/research facilities (OR 0.45; 95% CI 0.32-0.64; p < 0.01). CONCLUSIONS: Local ablative therapy for PCa treatment is more commonly offered among older and comorbid patients. Future studies should investigate the uptake of these technologies in non-hospital-based settings and in light of recent changes in insurance coverage.

Best Current Practice and Research Priorities in Active Surveillance for Prostate Cancer-A Report of a Movember International Consensus Meeting.

BACKGROUND: Active surveillance (AS) is recommended for low-risk and some intermediate-risk prostate cancer. Uptake and practice of AS vary significantly across different settings, as does the experience of surveillance-from which tests are offered, and to the levels of psychological support. OBJECTIVE: To explore the current best practice and determine the most important research priorities in AS for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: A formal consensus process was followed, with an international expert panel of purposively sampled participants across a range of health care professionals and researchers, and those with lived experience of prostate cancer. Statements regarding the practice of AS and potential research priorities spanning the patient journey from surveillance to initiating treatment were developed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Panel members scored each statement on a Likert scale. The group median score and measure of consensus were presented to participants prior to discussion and rescoring at panel meetings. Current best practice and future research priorities were identified, agreed upon, and finally ranked by panel members. RESULTS AND LIMITATIONS: There was consensus agreement that best practice includes the use of high-quality magnetic resonance imaging (MRI), which allows digital rectal examination (DRE) to be omitted, that repeat standard biopsy can be omitted when MRI and prostate-specific antigen (PSA) kinetics are stable, and that changes in PSA or DRE should prompt MRI ± biopsy rather than immediate active treatment. The highest ranked research priority was a dynamic, risk-adjusted AS approach, reducing testing for those at the least risk of progression. Improving the tests used in surveillance, ensuring equity of access and experience across different patients and settings, and improving information and communication between and within clinicians and patients were also high priorities. Limitations include the use of a limited number of panel members for practical reasons. CONCLUSIONS: The current best practice in AS includes the use of high-quality MRI to avoid DRE and as the first assessment for changes in PSA, with omission of repeat standard biopsy when PSA and MRI are stable. Development of a robust, dynamic, risk-adapted approach to surveillance is the highest research priority in AS for prostate cancer. PATIENT SUMMARY: A diverse group of experts in active surveillance, including a broad range of health care professionals and researchers and those with lived experience of prostate cancer, agreed that best practice includes the use of high-quality magnetic resonance imaging, which can allow digital rectal examination and some biopsies to be omitted. The highest research priority in active surveillance research was identified as the development of a dynamic, risk-adjusted approach.

Growth and renal function dynamics of renal oncocytomas in patients on active surveillance.

OBJECTIVES: To study the natural history of renal oncocytomas and address indications for intervention by determining how growth is associated with renal function over time, the reasons for surgery and ablation, and disease-specific survival. PATIENTS AND METHODS: The study was conducted in a retrospective cohort of consecutive patients with renal oncocytoma on active surveillance reviewed at the Specialist Centre for Kidney Cancer at the Royal Free London NHS Foundation Trust (2012 to 2019). Comparison between groups was performed using Mann-Whitney U-tests and chi-squared tests. A mixed-effects model with a random intercept for patient was used to study the longitudinal association between tumour size and estimated glomerular filtration rate (eGFR). RESULTS: Longitudinal data from 98 patients with 101 lesions were analysed. Most patients were men (68.3%) and the median (interquartile range [IQR]) age was 69 (13) years. The median (IQR) follow-up was 29 (26) months. Most lesions were small renal masses, and 24% measured over 4 cm. Over half (64.4%) grew at a median (IQR) rate of 2 (4) mm per year. No association was observed between tumour size and eGFR over time (P = 0.871). Nine lesions (8.9%) were subsequently treated. Two deaths were reported, neither were related to the diagnosis of renal oncocytoma. CONCLUSION: Natural history data from the largest active surveillance cohort of renal oncocytomas to date show that renal function does not seem to be negatively impacted by growing oncocytomas, and confirms clinical outcomes are excellent after a median follow-up of over 2 years. Active surveillance should be considered the 'gold standard' management of renal oncocytomas up to 7cm.

Mental health nurses' views and experiences of working with undergraduate nursing students: A descriptive exploratory study.

BACKGROUND: The core of pre-registration nursing education is the learning that takes place during the clinical placement. However, despite the fact that registered nurse preceptors are key players in supporting students during their placements there is a lack of literature examining the views of preceptors working with nursing students in mental health settings. OBJECTIVES: To explore mental health nurses' views and experiences of working with undergraduate nursing students and determine what factors influence this experience. DESIGN: A descriptive exploratory study approach using an on-line questionnaire was adopted for this study. SETTINGS: A specialist mental health service (SMHS) within one District Health Board in New Zealand. PARTICIPANTS: 89 registered nurses who had been involved in working with nursing students participated in this study. METHODS: Data was collected using an online questionnaire. RESULTS: The majority of the respondents in this study reported that they felt confident and well supported in the work they did with nursing students and had a positive perception of this role. However, one significant negative factor identified was the extra stress and workload pressure they reported when working with students, when no allowance was made for this. Another key finding was that engaging in some form of education related to the preceptorship role was positively correlated with nurses knowing what was required of them, feeling confident, the extent to which they planned clinical education, and feeling that they were sufficiently appreciated. CONCLUSIONS: Ensuring nurses have access to education related to clinical teaching and learning increases their confidence in the work they do with nursing students and has also been shown to have a positive impact on how they view this role.

Contemporary surgical management of renal oncocytoma: a nation's outcome.

OBJECTIVE: To report on the contemporary UK experience of surgical management of renal oncocytomas. PATIENTS AND METHODS: Descriptive analysis of practice and postoperative outcomes of patients with a final histological diagnosis of oncocytoma included in The British Association of Urological Surgeons (BAUS) nephrectomy registry from 01/01/2013 to 31/12/2016. Short-term outcomes were assessed over a follow-up of 60 days. RESULTS: Over 4 years, 32 130 renal surgical cases were recorded in the UK, of which 1202 were oncocytomas (3.7%). Most patients were male (756; 62.9%), the median (interquartile range [IQR]) age was 66.8 (13) years. The median (IQR; range) lesion size was 4.1 (3; 1-25) cm, 43.5% were ≤4 cm and 30.3% were 4-7 cm lesions. In all, 35 patients (2.9%) had preoperative renal tumour biopsy. Most patients had minimally invasive surgery, either radical nephrectomy (683 patients; 56.8%), partial nephrectomy (483; 40.2%) or other procedures (36; 3%). One in five patients (243 patients; 20.2%) had in-hospital complications: 48 were Clavien-Dindo classification grade ≥III (4% of the total cohort), including three deaths. Two additional deaths occurred within 60 days of surgery. The analysis is limited by the study's observational nature, not capturing lesions on surveillance or ablated after biopsy, possible underreporting, short follow-up, and lack of central histology review. CONCLUSION: We report on the largest surgical series of renal oncocytomas. In the UK, the complication rate associated with surgical removal of a renal oncocytoma was not negligible. Centralisation of specialist services and increased utilisation of biopsy may inform management, reduce overtreatment, and change patient outcomes for this benign tumour.

Attracting men to nursing: Is graduate entry an answer?

There is evidence which suggests that second degree graduate entry nursing programs may be a potential strategy to increase the number of men in nursing. This qualitative study used thematic analysis to describe the reasons underpinning men's enrolment in the first three intakes of the first such program in New Zealand. Interrogation of the data revealed two primary themes. First, in search of a satisfying career with the associated subthemes: was at a loss; fulfilment through working with and helping people; and a career with options. The second theme the time was right was underpinned by two subthemes: The right time of life; and, the right course. In contrast, to previous studies of men in nursing it was found that vertical career progression into management was not attractive, and that career satisfaction was seen as being able to help others. The findings may provide insight for developing strategies which encourage men's entry into nursing.

Surgical and Minimally Invasive Therapies for the Management of the Small Renal Mass.

PURPOSE OF REVIEW: This article aims to summarise recent developments in surgical and minimally invasive therapies in the management of small renal masses (SRMs). RECENT FINDINGS: The incidence of the small renal mass is increasing. Standard management of the SRM is partial nephrectomy. More recently, use of ablative techniques to manage the SRM has been increasing and an exciting array of technical advances is currently being made in the field. Nephron-sparing surgery looks set to become more financially viable with the advent of newer robotic platforms and, potentially, even less invasive with the evaluation of single-port access. Real-time imaging promises to improve tumour definition, nephron preservation and vascular management intraoperatively. Advances in surgical and minimally invasive therapies for the management of the SRM have the potential to improve cancer clearance and long-term renal function preservation. Patients will experience safer, more reliable and less invasive treatments for their small renal tumours. We describe the current advances underlying these changes.

Percutaneous nephrolithotomy access by urologist or interventional radiologist: practice and outcomes in the UK.

OBJECTIVE: To compare outcomes of urologist vs interventional radiologist (IR) access during percutaneous nephrolithotomy (PCNL) in the contemporary UK setting. PATIENTS AND METHODS: Data submitted to the British Association of Urological Surgeons PCNL data registry between 2009 and 2015 were analysed according to whether access was obtained by a urologist or an IR. We compared access success, number and type of tracts, and perceived and actual difficulty of access. Postoperative outcomes, including stone-free rates, lengths of hospital stay and complications, including transfusion rates, were also compared. RESULTS: Overall, percutaneous renal access was undertaken by an IR in 3453 of 5211 procedures (66.3%); this rate appeared stable over the entire study period for all categories of stone complexity and in cases where there was predicted or actual difficulty with access. Only 1% of procedures were abandoned because of failed access and this rate was identical in each group. IRs performed more multiple tract access procedures than urologists (6.8 vs 5.1%; P = 0.02), but had similar rates of supracostal punctures (8.2 vs 9.2%; P = 0.23). IRs used ultrasonograhpy more commonly than urologists to guide access (56.6% vs 21.7%, P < 0.001). There were no significant differences in complication rates, lengths of hospital stay or stone-free rates. CONCLUSIONS: Our findings suggest that favourable PCNL outcomes may be expected where access is obtained by either a urologist or an IR, assuming that they have received the appropriate training and that they are skilled and proficient in the procedure.

Assessment of Stone Complexity for PCNL: A Systematic Review of the Literature, How Best Can We Record Stone Complexity in PCNL?

INTRODUCTION: This study aims to systematically review the literature reporting tools for scoring stone complexity and the stratification of outcomes by stone complexity. In doing so, we aim to determine whether the evidence favors uniform adoption of any one scoring system. METHODS: PubMed and Embase databases were systematically searched for relevant studies from 2004 to 2014. Reports selected according to predetermined inclusion and exclusion criteria were appraised in terms of methodologic quality and their findings summarized in structured tables. RESULTS: After review, 15 studies were considered suitable for inclusion. Four distinct scoring systems were identified and a further five studies that aimed to validate aspects of those scoring systems. Six studies reported the stratification of outcomes by stone complexity, without specifically defining a scoring system. All studies reported some correlation between stone complexity and stone clearance. Correlation with complications was less clearly established, where investigated. CONCLUSIONS: This review does not allow us to firmly recommend one scoring system over the other. However, the quality of evidence supporting validation of the Guy's Stone Score is marginally superior, according to the criteria applied in this study. Further evaluation of the interobserver reliability of this scoring system is required.

Hospital Volume Does Not Influence the Safety of Percutaneous Nephrolithotomy in England: A Population-Based Cohort Study.

PURPOSE: This study aims to investigate the relationship between hospital case volume and safety-related outcomes after percutaneous nephrolithotomy (PCNL) within the English National Health Service (NHS). PATIENTS AND METHODS: The study used the Hospital Episode Statistics (HES) database, a routine administrative database, recording information on operations, comorbidity, and outcomes for all NHS hospital admissions in England. Records for all patients undergoing an initial PCNL between April 1, 2006 and March 31, 2012 were extracted. NHS trusts were divided into low-, medium-, and high-volume groups, according to the average annual number of PCNLs performed. We used multiple regression analyses to examine the associations between hospital volume and outcomes incorporating risk adjustment for sex, age, comorbidity, and hospital teaching status. Postoperative outcomes included: Emergency readmission, infection, and hemorrhage. Mean length of stay was also measured. RESULTS: There were 7661 index elective PCNL procedures performed in 163 hospital trusts, between April 2006 and March 2012. There were 2459 patients who underwent PCNL in the 116 units performing fewer than 10 PCNL procedures per year; 2643 patients in the 37 units performing 10 to 19 procedures per year; and 2459 patients in the 9 hospitals performing more than 20 procedures per year. For low-, medium-, and high-volume trusts, there was little variation in the rates of emergency readmission (L 9.7%, M 9.3%, H 8.4%), infection (3.0%, 4.2%, 3.8%), or hemorrhage (1.3%, 1.5%, 1.5%), and there was no statistical evidence that volume was associated with adjusted outcomes. Mean length of stay was slightly shorter in the medium- (5.0 days) and high-volume (5.0) groups compared with the low-volume group (5.3). The effect remained statistically significant after adjusted for confounding. CONCLUSION: Hospital volume was not associated with emergency readmission, infection, or hemorrhage. Length of stay appears to be shorter in higher volume units.

Cystinuria-a urologist's perspective.

Cystinuria is a genetic disease that leads to frequent formation of stones. In patients with recurrent stone formation, particularly patients <30 years old or those who have siblings with stone disease, urologists should maintain a high index of suspicion of the diagnosis of cystinuria. Patients with cystinuria require frequent follow-up and a multidisciplinary approach to diagnosis, prevention and management. Patients have reported success in preventing stone episodes by maintaining dietary changes using a tailored review from a specialist dietician. For patients who do not respond to conservative lifestyle measures, medical therapy to alkalinize urine and thiol-binding drugs can help. A pre-emptive approach to the surgical management of cystine stones is recommended by treating smaller stones with minimally invasive techniques before they enlarge to a size that makes management difficult. However, a multimodal approach can be required for larger complex stones. Current cystinuria research is focused on methods of monitoring disease activity, novel drug therapies and genotype-phenotype studies. The future of research is collaboration at a national and international level, facilitated by groups such as the Rare Kidney Stone Consortium and the UK Registry of Rare Kidney Diseases.

The changing face of urinary continence surgery in England: a perspective from the Hospital Episode Statistics database.

OBJECTIVE: To quantify changes in surgical practice in the treatment of stress urinary incontinence (SUI), urge urinary incontinence (UUI) and post-prostatectomy stress incontinence (PPI) in England, using the Hospital Episode Statistics (HES) database. PATIENTS AND METHODS: We used public domain information from the HES database, an administrative dataset recording all hospital admissions and procedures in England, to find evidence of change in the use of various surgical procedures for urinary incontinence from 2000 to 2012. RESULTS: For the treatment of SUI, a general increase in the use of synthetic mid-urethral tapes, such as tension-free vaginal tape (TVTO) and transobturator tape (TOT), was observed, while there was a significant decrease in colposuspension procedures over the same period. The number of procedures to remove TVT and TOT has also increased in recent years. In the treatment of overactive bladder and UUI, there has been a significant increase in the use of botulinum toxin A and neuromodulation in recent years. This coincided with a steady decline in the recorded use of clam ileocystoplasty. A steady increase was observed in the insertion of artificial urinary sphincter (AUS) devices in men, related to PPI. CONCLUSIONS: Mid-urethral synthetic tapes now represent the mainstream treatment of SUI in women, but tape-related complications have led to an increase in procedures to remove these devices. The uptake of botulinum toxin A and sacral neuromodulation has led to fewer clam ileocystoplasty procedures being performed. The steady increase in insertions of AUSs in men is unsurprising and reflects the widespread uptake of radical prostatectomy in recent years. There are limitations to results sourced from the HES database, with potential inaccuracy of coding; however, these data support the trends observed by experts in this field.