Focused UTUC pathways with a risk-stratified approach to diagnostic ureteroscopy: is it the need of the hour? A retrospective cohort analysis.

INTRODUCTION: Upper urinary tract urothelial cancer is a rare, aggressive variant of urinary tract cancer. There is often delay to diagnosis and management for this entity in view of diagnostic and staging challenges needing additional investigations and risk stratifications for improved outcomes. In this article, we share our experience in developing a dedicated diagnostic and treatment pathway for UTUC and assess its impact on time lines to radical nephroureterectomy (RNU). We also evaluate the impact of diagnostic ureteroscopy (DUR) on UTUC care pathways timelines. MATERIALS AND METHODS: A prospective database was maintained for all patients who underwent a RNU from January 2015 to August 2022 in a high-volume single tertiary care centre in the UK. In 2019, a Focused UTUC pathway (FUP) was implemented at the centre to streamline diagnostic and RNU pathways. A retrospective analysis of the database was conducted to compare time lines and diagnostic trends between the pre-FUP and FUP cohorts. Primary outcome measures were time to RNU from MDT. Secondary outcome measures were: impact of DUR on time to RNU from MDT and negative UTUC rates between DUR and non-DUR cohorts. Differences in continuous variables across categories were assessed using the independent sample t test. Categorical variables between cohorts were analysed using the chi-square (χ2). Statistical significance in this study was set as p < 0.05. RESULTS: A total of 500 patients with complete data were included in the analysis. The pre-FUP and FUP cohorts consisted of 313 patients and 187 patients, respectively. The overall cohort had a mean age (SD) of 70 years (9.3). 66% of the overall cohort were males. The median time to RNU from MDT in the FUP was significantly lower compared to the pre-FUP cohort; 62 days (IQR 59) vs. 48 days (IQR 41.5), p < 0.0001. The median time to RNU from MDT in patients who underwent a diagnostic URS in the FUP cohort was significantly lower compared to the pre-FUP cohort; 78.5 days (IQR 54.8) vs. 68 days (IQR 48), p-NS. The non-UTUC rates in the DUR and non-DUR cohorts were 6/248 (2.4%) and 14/251 (5.6%), respectively (NS). CONCLUSION: In this series, we illustrate the effectiveness of integrating a multidisciplinary approach with specialised personnel, ring-fenced clinics, efficient diagnostic assessment and optimised theatre capacity. By adopting a risk-stratified approach to diagnostic ureteroscopy, we have achieved a significant reduction in time to RNU.

The Impact of Non-Compliance to a Standardized Risk-Adjusted Protocol on Recurrence, Progression, and Mortality in Non-Muscle Invasive Bladder Cancer.

PURPOSE: Non-muscle invasive bladder cancer (NMIBC) is a potentially curable or controllable disease if strict adherence to a surveillance protocol is followed. Management and surveillance of NMIBC begins at the time of diagnosis up to a few years thereafter. There is scanty data in the literature evaluating the impact of non-compliance with the surveillance protocols on progression, recurrence, and mortality rate. PATIENTS AND METHODS: An observational, retrospective cohort study recruited data between 2012 and 2017 at two tertiary hospitals. Data were collected consecutively. NMIBC patients who had at least 3 years of follow-up data were included. Patients were divided into different groups based on their compliance with the cystoscopy follow-up protocol as recommended by the European guidelines. We compared the cystoscopy compliant group with the non-compliant group in view of recurrence, progression, and mortality. In addition, missing variable items during surveillance were calculated using a new scoring model to predict adverse outcomes. RESULTS: Eighty-eight NMIBC patients met our criteria. Recurrence rate (RR), progression rate (PR), metastasis rate (MsR), and mortality rate (MR) are significantly higher in non-compliant group, RR: (92.6%) (P<0.001), PR: (54.1%) (P<0.001), MsR: (37.7%) (P<0.001), MR: (23.5%) (P= 0.002) respectively. In the subgroup analysis, intermediate and high-risk groups have a PR rate of zero in the compliant group, while it is 100% (P<0.001) and 56.4% (P=0.001) in the non-compliant group, respectively. Use of a Kaplan Meier (KM) graph shows that compliant patients had a better survival in comparison to non-compliant patients. Scoring there or more is statistically and clinically significantly associated with higher recurrence, progression, and mortality. RR: (94%) (P=0.016), PR: 49% (P<0.001) and MR (26%) (P=0.012). CONCLUSION: Non-compliance to a standardized surveillance protocol in NMIBC is associated statistically and clinically with adverse outcomes in comparison to a compliant group. This mandates strict adherence to surveillance guidelines particularly in patients with high-risk disease.

Penile Fracture: A Meta-Analysis.

OBJECTIVES: To review the causes and management of penile fracture and to compare between surgical and conservative management as well as immediate and delayed interventions in terms of overall and specific complications. METHODS: A search of all reported literature was conducted for all articles reporting on the management and outcomes of penile fractures. Full texts of relevant articles were obtained and screened according to the inclusion criteria. Outcomes measures were numbers of patients receiving surgical or conservative management, aetiology of fracture, length of admission, complications as well as the specifics of diagnostic approaches and operative management. Data was collated and where possible meta-analysed using Revman software. RESULTS: A total of 58 relevant studies involving 3,213 patients demonstrated that intercourse accounts for only 48% of cases with masturbation and forced flexion accounting for 39%. Meta-analysis shows that surgical intervention was associated with significantly fewer complications vs. conservative management (p < 0.000001). Surgical intervention results in significantly less erectile dysfunction (ED), curvature and painful erection than conservative management. There was no significant difference in the number of patients developing plaques/nodules (p = 0.94). Meta-analysis shows that overall early surgery is preferable to delayed surgery but that rates of ED are not significantly different. DISCUSSION: Early surgical intervention is associated with significantly fewer complications than conservative management or delayed surgery. The combined outcome of rapid diagnosis by history and clinical examination and swift surgical intervention is key for reconstruction with minimal long-term complications.