Archive for category: Latest Articles

Four Phases in the Metamorphosis of The Consultant Urologist

Abstract

Urology has been deemed the happiest surgical specialty in a United States survey of >250,000 surgeons[1] , similar to the UK. So, what does a career of a urologist in the UK really look like?

The average career of a urologist is 37 years, 1/3 in training and 2/3 as a Consultant[2], with most urologists under the age of 43 years working to 68 to achieve UK state pension age (SPA). As most consultants currently retire at 61[2], this poses workforce issues; young consultants will need to work for longer, to fund the gap to their extended SPA; earlier retirement of more senior generations erodes provision of urological services[3,4], and reduces the continuity of corporate memory. A retention, and overlap, of both junior and senior consultant urologists using an empathic team approach is, therefore, vital to prevent diminution of the number in, and the knowledge base of, the talented and productive senior component of the workforce. Here, we will attempt to walk in another’s shoes, defining stages in urological careers to attempt to understand drivers to premature departure from the profession.

Prostate cancer in transgender women: what does a urologist need to know?

Abstract

Objective

To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs.

Materials and methods

We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women.

Results

Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women.

Conclusion

The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

Clinical Efficacy of Mebeverine for Persistent Nocturnal Enuresis after Orthotopic W‐Neobladder

Abstract

Objective

To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs.

Materials and methods

We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women.

Results

Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women.

Conclusion

The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

Multicentric Prospective Local Treatment of Metastatic Prostate Cancer (LoMP) Study

Abstract

Objective

To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs.

Materials and methods

We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women.

Results

Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women.

Conclusion

The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

Current status of Thulium Fiber Laser (TFL) lithotripsy: An up‐to‐date review

Abstract

Introduction

Thulium Fiber Laser (TFL) is the latest laser technology, which has gained increased attention for its role in stone lithotripsy. Findings from in vitro studies have shown that it can potentially deliver reduced retropulsion and efficient stone clearance. A number of clinical studies on TFL have now been reported.

Our aim was to perform an up-to-date review to scope its current status in stone lithotripsy and provide a guide for the clinical urologist

Methods

A review of world literature was performed in order to identify original articles on TFL for stone lithotripsy. Our clinical experiences of using the technology have also been shared.

Results

To date there have been 11 clinical studies published on TFL for stone lithotripsy. Three of these have been in the setting of mini percutaneous nephrolithotomy (PCNL) and the remainder have been on ureteroscopy (URS). There has only been one randomised study on this technology, which has been for URS. For URS, range of settings has been 0.1-4J x 7-300Hz for both URS and mini PCNL. Stones ranging from 0.4-3.2cm and 1.5-3cm have been treated with URS and mini PCNL, respectively. Final stone free rate (SFR) for TFL has ranged from 66.6 -100% and 85-100% for URS and mini PCNL respectively. Average length of stay ranged from 0.5-2.4 days in URS group but no studies reported this for mini PCNL. Operative times in all the studies (both URS and mini PCNL) were less than 60 minutes.

Conclusion

Initial clinical studies reveal that TFL appears to be efficacious in setting of stone lithotripsy. However, further randomised trials are warranted to delineate its formal position as well as determine the optimal settings for use in clinical practice.

Radiation Treatment in Prostate Cancer: Covering the Waterfront

Abstract

Introduction

Thulium Fiber Laser (TFL) is the latest laser technology, which has gained increased attention for its role in stone lithotripsy. Findings from in vitro studies have shown that it can potentially deliver reduced retropulsion and efficient stone clearance. A number of clinical studies on TFL have now been reported.

Our aim was to perform an up-to-date review to scope its current status in stone lithotripsy and provide a guide for the clinical urologist

Methods

A review of world literature was performed in order to identify original articles on TFL for stone lithotripsy. Our clinical experiences of using the technology have also been shared.

Results

To date there have been 11 clinical studies published on TFL for stone lithotripsy. Three of these have been in the setting of mini percutaneous nephrolithotomy (PCNL) and the remainder have been on ureteroscopy (URS). There has only been one randomised study on this technology, which has been for URS. For URS, range of settings has been 0.1-4J x 7-300Hz for both URS and mini PCNL. Stones ranging from 0.4-3.2cm and 1.5-3cm have been treated with URS and mini PCNL, respectively. Final stone free rate (SFR) for TFL has ranged from 66.6 -100% and 85-100% for URS and mini PCNL respectively. Average length of stay ranged from 0.5-2.4 days in URS group but no studies reported this for mini PCNL. Operative times in all the studies (both URS and mini PCNL) were less than 60 minutes.

Conclusion

Initial clinical studies reveal that TFL appears to be efficacious in setting of stone lithotripsy. However, further randomised trials are warranted to delineate its formal position as well as determine the optimal settings for use in clinical practice.

Pain‐Free TRUS B: A phase 3 double‐blind placebo‐controlled randomized trial of methoxyflurane with periprostatic local anaesthesia to reduce the discomfort of transrectal ultrasound‐guided prostate biopsy (ANZUP 1501)

Abstract

Introduction

Thulium Fiber Laser (TFL) is the latest laser technology, which has gained increased attention for its role in stone lithotripsy. Findings from in vitro studies have shown that it can potentially deliver reduced retropulsion and efficient stone clearance. A number of clinical studies on TFL have now been reported.

Our aim was to perform an up-to-date review to scope its current status in stone lithotripsy and provide a guide for the clinical urologist

Methods

A review of world literature was performed in order to identify original articles on TFL for stone lithotripsy. Our clinical experiences of using the technology have also been shared.

Results

To date there have been 11 clinical studies published on TFL for stone lithotripsy. Three of these have been in the setting of mini percutaneous nephrolithotomy (PCNL) and the remainder have been on ureteroscopy (URS). There has only been one randomised study on this technology, which has been for URS. For URS, range of settings has been 0.1-4J x 7-300Hz for both URS and mini PCNL. Stones ranging from 0.4-3.2cm and 1.5-3cm have been treated with URS and mini PCNL, respectively. Final stone free rate (SFR) for TFL has ranged from 66.6 -100% and 85-100% for URS and mini PCNL respectively. Average length of stay ranged from 0.5-2.4 days in URS group but no studies reported this for mini PCNL. Operative times in all the studies (both URS and mini PCNL) were less than 60 minutes.

Conclusion

Initial clinical studies reveal that TFL appears to be efficacious in setting of stone lithotripsy. However, further randomised trials are warranted to delineate its formal position as well as determine the optimal settings for use in clinical practice.

Women doctors in female urology: current status and implications for future workforce

Objective

To assess automatic computer-aided in situ recognition of the morphological features of pure and mixed urinary stones using intra-operative digital endoscopic images acquired in a clinical setting.

Materials and Methods

In this single-centre study, a urologist with 20 years’ experience intra-operatively and prospectively examined the surface and section of all kidney stones encountered. Calcium oxalate monohydrate (COM) or Ia, calcium oxalate dihydrate (COD) or IIb, and uric acid (UA) or IIIb morphological criteria were collected and classified to generate annotated datasets. A deep convolutional neural network (CNN) was trained to predict the composition of both pure and mixed stones. To explain the predictions of the deep neural network model, coarse localization heat-maps were plotted to pinpoint key areas identified by the network.

Results

This study included 347 and 236 observations of stone surface and stone section, respectively; approximately 80% of all stones exhibited only one morphological type and approximately 20% displayed two. A highest sensitivity of 98% was obtained for the type ‘pure IIIb/UA’ using surface images. The most frequently encountered morphology was that of the type ‘pure Ia/COM’; it was correctly predicted in 91% and 94% of cases using surface and section images, respectively. Of the mixed type ‘Ia/COM + IIb/COD’, Ia/COM was predicted in 84% of cases using surface images, IIb/COD in 70% of cases, and both in 65% of cases. With regard to mixed Ia/COM + IIIb/UA stones, Ia/COM was predicted in 91% of cases using section images, IIIb/UA in 69% of cases, and both in 74% of cases.

Conclusions

This preliminary study demonstrates that deep CNNs are a promising method by which to identify kidney stone composition from endoscopic images acquired intra-operatively. Both pure and mixed stone composition could be discriminated. Collected in a clinical setting, surface and section images analysed by a deep CNN provide valuable information about stone morphology for computer-aided diagnosis.

Don’t SPARE me: details matter!

Objectives

To report the functional outcomes of robot-assisted laparoscopic artificial urinary sphincter implantation (R-AUS) in men with neurogenic stress urinary incontinence (SUI).

Patients and Methods

A monocentric retrospective study included all consecutive adult male neuro-urological patients who underwent R-AUS for SUI between January 2011 and August 2018. The AUS was implanted via a transperitoneal robot-assisted laparoscopic approach. Intraoperative and early postoperative complications were reported (Clavien–Dindo classification). Continence was defined as no pad usage. Revision and explantation rates were also evaluated.

Results

Overall, 19 men with a median (interquartile range [IQR]) age of 45 (37–54) years were included. No conversion to laparotomy was needed. Three minor (Clavien–Dindo Grade I–II) early postoperative complications occurring in three (15.8%) patients were reported. The median (IQR) follow-up was 58 (36–70) months. At the end of the follow-up, the continence rate was 89.5%. The AUS revision and explantation rates were 5.3% and 0%, respectively.

Conclusion

A R-AUS is a safe and efficient procedure for AUS implantation in adult male neuro-urological patients, referring to the challenging open technique.

A Randomized Trial on Clinical Outcomes and Stent Related Symptoms Following Intraureteral Stent on a String versus Conventional Stent Placement

Abstract

Introduction and objective

To minimize stent-related symptoms (SRS), a modified complete intra-ureteral stent with extraction suture was designed. The objective was to compare SRS of the conventional DJ stent and the complete intraureteral stent using the validated Ureteral Stent Symptom Questionnaire (USSQ).

Materials and Methods

We randomized 124 patients after uncomplicated ureteroscopic lithotripsy into complete intraureteral stent (CIUS) and conventional DJ stent (CUS) placement group. The USSQ scores were evaluated on postoperative day 1, day 7 (just before stent removal) and 4 weeks after stent removal (control values). Pain scores after stent removal were also recorded using visual analogue scale (VAS). Sub-domain analysis of all stent related symptoms and stent related complications were also compared.

Results

No significant intergroup differences were found in the domain scores of urinary symptoms (P = 0.74), pain (P = 0.32), general health (P = 0.27), work (P = 0.24), or additional problems (P = 0.29). However, statistically significant difference was noted on VAS scores (P = 0.015). Analysis of sub-domains of USSQ item scores revealed the CIUS group had significantly better scores for ‘‘urge incontinence’’ (1.21 vs. 1.00; p = <0.001), ‘‘discomfort on voiding’’ (2.07 vs. 1.50; p = <0.001), ‘‘difficulties with respect to light physical activity’’ (1.131 vs. 1.00; p = <0.001), ‘‘fatigue’’ (1.84 vs. 1.57; p = 0.002), “feeling comfortable” (3.68 vs. 3.16; p = 0.003), ‘‘need for extra help’’ (1.96 vs. 1.00; p = <0.001), and ‘‘change in duration of work’’(4.27 vs. 1.86; p = <0.001). However, the patients in the CIUS group were sexually inactive for the time till stent was indwelling (mean: 7.34 days). There was no difference in the complication rate between the 2 groups.

Conclusion

The use of complete intra ureteral stent placement with strings after URS decreases SRS.

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