A Systematic Review of Focal Ablative Therapy for Clinically Localised Prostate Cancer in Comparison with Standard Management Options: Limitations of the Available Evidence and Recommendations for Clinical Practice and Further Research.

CONTEXT: The clinical effectiveness of focal therapy (FT) for localised prostate cancer (PCa) remains controversial. OBJECTIVE: To analyse the evidence base for primary FT for localised PCa via a systematic review (SR) to formulate clinical practice recommendations. EVIDENCE ACQUISITION: A protocol-driven, PRISMA-adhering SR comparing primary FT (sub-total, focal, hemi-gland, or partial ablation) versus standard options (active surveillance [AS], radical prostatectomy [RP], or external beam radiotherapy [EBRT]) was undertaken. Only comparative studies with ≥50 patients per arm were included. Primary outcomes included oncological, functional, and quality-of-life outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Eligible SRs were reviewed and appraised (AMSTAR) and ongoing prospective comparative studies were summarised. EVIDENCE SYNTHESIS: Out of 1119 articles identified, four primary studies (1 randomised controlled trial [RCT] and 3 retrospective studies) recruiting 3961 patients and ten eligible SRs were identified. Only qualitative synthesis was possible owing to clinical heterogeneity. Overall, RoB and confounding were moderate to high. An RCT comparing vascular-targeted focal photodynamic therapy (PDT) with AS found a significantly lower rate of treatment failure at 2 yr with PDT. There were no differences in functional outcomes, although PDT was associated with worse transient adverse events. However, the external validity of the study was contentious. A retrospective study comparing focal HIFU with robotic RP found no significant differences in treatment failure at 3 yr, with focal HIFU having better continence and erectile function recovery. Two retrospective cohort studies using Surveillance, Epidemiology and End Results data compared focal laser ablation (FLA) against RP and EBRT, reporting significantly worse oncological outcomes for FLA. The overall data quality and applicability of the primary studies were limited because of clinical heterogeneity, RoB and confounding, lack of long-term data, inappropriate outcome measures, and poor external validity. Virtually all the SRs identified concluded that there was insufficient high-certainty evidence to make definitive conclusions regarding the clinical effectiveness of FT, with the majority of SRs judged to have a low or critically low confidence rating. Eight ongoing prospective comparative studies were identified. Ways of improving the evidence base are discussed. CONCLUSIONS: The certainty of the evidence regarding the comparative effectiveness of FT as a primary treatment for localised PCa was low, with significant uncertainties. Until higher-certainty evidence emerges from robust prospective comparative studies measuring clinically meaningful outcomes at long-term time points, FT should ideally be performed within clinical trials or well-designed prospective cohort studies. PATIENT SUMMARY: We examined the literature to determine the effectiveness of prostate-targeted treatment compared with standard treatments for untreated localised prostate cancer. There was no strong evidence showing that focal treatment compares favourably with standard treatments; consequently, focal treatment is not recommended for routine standard practice.

A Narrative Overview of Active Surveillance for Clinically Localised Prostate Cancer.

BACKGROUND: -Active surveillance (AS) is a strategy employed as an alternative to immediate standard active treatments for patients with low-risk localised prostate cancer (PCa). Active treatments such as radical prostatectomy and radiotherapy are associated with significant adverse effects which impair quality of life. The majority of patients with low-risk PCa undergo a slow and predictable course of cancer growth and do not require immediate curative treatment. AS provides a means to identify and monitor patients with low-risk PCa through regular PSA testing, imaging using MRI scans and regular repeat prostate biopsies. These measures enable the identification of progression, or increase in cancer extent or aggressiveness, which necessitates curative treatment. Alternatively, some patients may choose to leave AS to pursue curative interventions due to anxiety. The main benefit of AS is the avoidance of unnecessary radical treatments for patients at the early stages of the disease, hence avoiding over-treatment, whilst identifying those at risk of progression to be treated actively. The objective of this article is to provide a narrative summary of contemporary practice regarding AS based on a review of the available evidence base and clinical practice guidelines. Elements of discussion include the clinical effectiveness and harms of AS, what AS involves for healthcare professionals, and patient perspectives. The pitfalls and challenges for healthcare professionals are also discussed. DATA SOURCES: We consulted international guidelines, collaborative studies and seminal prospective studies on AS in the management of clinically localised PCa. CONCLUSION: AS is a feasible alternative to radical treatment options for low-risk PCa, primarily as a means of avoiding over-treatment, whilst identifying those who are at risk of disease progression for active treatment. There is emerging data demonstrating the long-term safety of AS as an oncological management strategy. Uncertainties remain regarding variation in definitions, criteria, thresholds and the most effective types of diagnostic interventions pertaining to patient selection, monitoring and reclassification. Efforts have been made to standardise the practice and conduct of AS. As data from high-quality prospective comparative studies mature, the practice of AS will continue to evolve. IMPLICATIONS FOR NURSING PRACTICE: The practice of AS involves a multi-disciplinary team of healthcare professionals consisting of nurses, urologists, oncologists, pathologists and radiologists. Nurses play a prominent role in managing AS programmes, and are closely involved in patient selection and recruitment, counselling, organising and administering diagnostic interventions including prostate biopsies, and ensuring patients' needs are being met throughout the duration of AS.

Restoration of the Lost Obscured Coronal Sulcus: A Novel Surgical Technique for Penile Lichen Sclerosus with Severe Preputial Adhesions.

BACKGROUND: Lichen sclerosus (LS) may cause the glans and prepuce to become fused, making a standard circumcision impossible. Most authorities recommend excision of the fused area with glans resurfacing, although partial circumcision is often performed. OBJECTIVE: To evaluate an alternative technique that preserves the fused area and allows a complete circumcision without grafting. DESIGN, SETTING, AND PARTICIPANTS: Over 3 yr (January 2016-March 2018), 28 men (age 28-93 yr; mean 62 yr) underwent the restoration of lost obscured coronal sulcus (ROLOCS) procedure with over 1 yr of follow-up. Complications were reviewed retrospectively with an additional survey. SURGICAL PROCEDURE: The shaft skin is incised at the corona. Dartos is divided, which allows antegrade dissection just outside the fused glans membrane. The foreskin is removed and shaft skin sutured to dartos below the corona. MEASUREMENTS: Postoperative pain, aesthetic satisfaction, sexual enjoyment, glans sensation, and urinary symptoms were measured. RESULTS AND LIMITATIONS: There were no major complications. In all cases, the coronal sulcus was restored and the glans skin became soft without skin grafting. All were satisfied with the aesthetics. Of the patients, <70% experienced mild to low-moderate pain; 55% and 25% had, respectively, improved or reduced glans sensation; and 40% reported improved enjoyment of sex. Histology showed LS in all cases with squamous cell carcinoma in four, including three out of five patients who had previously undergone partial circumcision. Although this is the largest series reported yet, the numbers were too small for a meaningful statistical analysis. CONCLUSIONS: The ROLOCS operation offers an aesthetically superior alternative to partial circumcision and is easier to perform with less morbidity than skin grafting. PATIENT SUMMARY: The restoration of lost obscured coronal sulcus (ROLOCS) procedure provides an alternative to partial circumcision or circumcision with skin grafting when the foreskin is welded to the head of the penis (glans) due to lichen sclerosus. It produces a good cosmetic result, but the glans can be sore until it heals.

Does the introduction of prostate multiparametric magnetic resonance imaging into the active surveillance protocol for localized prostate cancer improve patient re-classification?

OBJECTIVES: To determine whether replacement of protocol-driven repeat prostate biopsy (PB) with multiparametric magnetic resonance imaging (mpMRI) ± repeat targeted prostate biopsy (TB) when evaluating men on active surveillance (AS) for low-volume, low- to intermediate-risk prostate cancer (PCa) altered the likelihood of or time to treatment, or reduced the number of repeat biopsies required to trigger treatment. PATIENTS AND METHODS: A total of 445 patients underwent AS in the period 2010-2016 at our institution, with a median (interquartile range [IQR]) follow-up of 2.4 (1.2-3.7) years. Up to 2014, patients followed a 'pre-2014' AS protocol, which incorporated PB, and subsequently, according to the 2014 National Institute for Health and Care Excellence (NICE) guidelines, patients followed a '2014-present' AS protocol that included mpMRI. We identified four groups of patients within the cohort: 'no mpMRI and no PB'; 'PB alone'; 'mpMRI ± TB'; and 'PB and mpMRI ± TB'. Kaplan-Meier plots and log-rank tests were used to compare groups. RESULTS: Of 445 patients, 132 (30%) discontinued AS and underwent treatment intervention, with a median (IQR) time to treatment of 1.55 (0.71-2.4) years. The commonest trigger for treatment was PCa upgrading after mpMRI and TB (43/132 patients, 29%). No significant difference was observed in the time at which patients receiving a PB alone or receiving mpMRI ± TB discontinued AS to undergo treatment (median 1.9 vs 1.33 years; P = 0.747). Considering only those patients who underwent repeat biopsy, a greater proportion of patients receiving TB after mpMRI discontinued AS compared with those receiving PB alone (29/66 [44%] vs 32/87 [37%]; P = 0.003). On average, a single set of repeat biopsies was needed to trigger treatment regardless of whether this was a PB or TB. CONCLUSIONS: Replacing a systematic PB with mpMRI ±TB as part of an AS protocol increased the likelihood of re-classifying patients on AS and identifying men with clinically significant disease requiring treatment. mpMRI ±TB as part of AS thereby represents a significant advance in the oncological safety of the AS protocol.

Safety and Efficacy of Permacol Injection in the Treatment of Fecal Incontinence.

PURPOSE: Permacol has been gaining popularity in recent times for the treatment of fecal incontinence (FI). This study aims to evaluate the safety and efficacy of anal submucosal Permacol injection in the treatment of FI. METHODS: All consecutive patients who underwent Permacol injection for FI over a 3-year period were included. Patients' data relating to obstetric history, anorectal/pelvic operations, type of FI, preoperative anorectal physiology results and follow-up details for outcome measures were collected. Preoperative and postoperative Cleveland Clinic Florida Incontinence Scores (CCFISs) were noted. Patients were surveyed by using a telephone questionnaire to assess the quality of life and other outcome measures. Data were analysed using SPSS ver.19.0. RESULTS: Thirty patients (28 females and 2 males) with a median age of 67 years were included in the study. Of those patients, 37%, 50%, and 13% were noted to have passive, mixed and urge FI, respectively. Six of the patients (20%) had repeat Permacol injections, 5 of whom had sustained responses to the first Permacol injection for a mean of 11 months. There was a significant improvement in the CCFIS from a baseline median of 12.5, mean 12.8 interquartile range [IQR], 6-20), to a median of 3.5, mean 4.8 (IQR, 0-20), P < 0.001. Of the patients surveyed by telephone 89% were satisfied with their overall experience and the improvement in their symptoms following Permacol injections. CONCLUSION: This study has demonstrated that Permacol injection for the treatment of FI is safe and effective and has no associated major complications. However, the results are not permanent; consequently, a significant proportion of the patients with an initial response may require repeat injections.

Acute coronary thrombosis and multiple coronary aneurysms in a 22-year-old man with the human immunodeficiency virus.

The human immunodeficiency virus (HIV) can cause diverse cardiovascular complications. In HIV patients on antiretroviral therapy, the prevalence of myocardial infarction has steadily increased over the years. Young patients who are naïve to antiretroviral therapy and who experience coronary events are not well represented in the medical literature. We describe the case of a 22-year-old man, infected with HIV for 4 years and never treated with antiretroviral therapy, who emergently presented with a non-ST-segment-elevation myocardial infarction. Coronary angiograms revealed thrombosis and multiple coronary artery aneurysms; however, no areas of atherosclerotic stenosis were apparent. He was successfully treated with coronary stenting, antiplatelet therapy, and anticoagulation. Nine months after the initial presentation, he exhibited excellent exercise capacity, and no ischemia was evident. We discuss the various therapeutic approaches in this case.

Engineering efficient technology transfer.

Academic and industry leaders strategize for efficient translation of university-driven biomedical engineering innovations.

Evaluation of NOC standardized outcome of "health seeking behavior" in nurse-managed clinics.

This study evaluated the accomplishment of the Nursing Outcomes Classification (NOC) outcome "Health Seeking Behavior" in 5 nurse-managed clinics. Nurse practitioners and registered nurses rated patients on 11 indicators of health seeking behaviors, and recorded their level of knowledge of the patient. A total of 556 evaluations were collected. Health seeking behavior scores were lowest in a rural county school-based clinic and highest in a federally qualified health center. Ratings increased with nurses' knowledge of patients and for older patients.

Health care in Appalachia: a population-based approach.

The health status of people who live in the rural, coal-producing counties of southwest Virginia remains problematic despite an apparent high primary care provider-to-population threshold. This descriptive exploratory study surveyed 922 households representing 2,188 people, with regard to the availability, need, and access to health care services. Findings indicated a population who had a greater morbidity for chronic illnesses such as heart disease and hypertension than the rest of the state, a large number of people without health and prescription coverage, and an overall perception of fair-to-poor health status. Findings also indicated a substantial proportion of the population who were in need of dental and visual care and general preventive services and those who were dealing with depression at home without outside intervention. One disturbing finding was the large number of people who shared prescriptive medications with family and friends. The Community As Partner Model might be used by community health nurses in this region to help structure interventions. Overall findings suggest a need for interventions aimed at screening for depression, managing prescriptive medications, and identification of low-cost and free preventive, dental, and visual care services.