The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study

Objective To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. Patients and Methods This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. Results Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3–34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1–30.2), UTUC (n = 128) 1.14% (95% CI 0.77–1.52), renal cancer (n = 107) 1.05% (95% CI 0.80–1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32–2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03–1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90–4.15; P < 0.001), male sex 1.30 (95% CI 1.14–1.50; P < 0.001), and smoking 2.70 (95% CI 2.30–3.18; P < 0.001). Conclusions A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer

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

Photoselective vaporisation of the prostate using 80-W and 120-W laser versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review with meta-analysis from 2002 to 2012

Context: Photoselective vaporisation (PVP) of the prostate is being used increasingly to treat symptomatic benign prostatic hyperplasia, due to the associated lower morbidity. Holmium laser enucleation of the prostate was considered to be the treatment with the highest evidence; however, evidence for PVP has dramatically increased recently. Objective: To conduct a systematic review and meta-analysis of level 1 evidence studies to determine the effectiveness of PVP versus transurethral resection of the prostate (TURP) for surgical treatment of benign prostatic hyperplasia. Outcomes reviewed included perioperative data, complications, and functional outcomes. Evidence acquisition: Biomedical databases from 2002 to 2012 and American Urological Association and European Association of Urology conference proceedings from 2007 to 2011 were searched. Trials were included if they were randomised controlled trials, had PVP as the intervention, and TURP as control. Meta-analysis was performed using a random effects model. Evidence synthesis: Nine trials were identified with 448 patients undergoing PVP (80 W in five trials and 120 W in four trials) and 441 undergoing TURP. Catheterisation time and length of stay were shorter in the PVP group by 1.91 d (95% confidence interval [CI], 1.47-2.35; p < 0.00001) and 2.13 d (95% CI, 1.78-2.48; p < 0.00001), respectively. Operation time was shorter in the TURP group by 19.64 min (95% CI, 9.05-30.23; p = 0.0003). Blood transfusion was significantly less likely in the PVP group (risk ratio: 0.16; 95% CI, 0.05-0.53; p = 0.003). There were no significant differences between PVP and TURP when comparing other complications. Regarding functional outcomes, six studies found no difference between PVP and TURP, two favoured TURP, and one favoured PVP. Conclusions: Perioperative outcomes of catheterisation time and length of hospital stay were shorter with PVP, whereas operative time was longer with PVP. Postoperative complications of blood transfusion and clot retention were significantly less likely with PVP; no difference was noted in other complications. Overall, no difference was noted in intermediate-term functional outcomes

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

International urology journal club via twitter: 12-month experience

Background Online journal clubs have increasingly been utilised to overcome the limitations of the traditional journal club. However, to date, no reported online journal club is available for international participation. Objective To present a 12-mo experience from the International Urology Journal Club, the world's first international journal club using Twitter, an online micro-blogging platform, and to demonstrate the viability and sustainability of such a journal club. Design, setting, and participants #urojc is an asynchronous 48-h monthly journal club moderated by the Twitter account @iurojc. The open invitation discussions focussed on papers typically published within the previous 2-4 wk. Data were obtained via third-party Twitter analysis services. Outcome measurements and statistical analysis Outcomes analysed included number of total and new users, number of tweets, and qualitative analysis of the relevance of tweets. Analysis was undertaken using GraphPad software, Microsoft Excel, and thematic qualitative analysis. Results and limitations The first 12 mo saw a total of 189 unique users representing 19 countries and 6 continents. There was a mean of 39 monthly participants that included 14 first-time participants per month. The mean number of tweets per month was 195 of which 62% represented original tweets directly related to the topic of discussion and 22% represented retweets of original posts. A mean of 130 832 impressions, or reach, were created per month. The @iurojc moderator account has accumulated >1000 followers. The study is limited by potentially incomplete data extracted by third-party Twitter analysers. Conclusions Social media provides a potential for enormous international communication that has not been possible in the past. We believe the pioneering #urojc is both viable and sustainable. There is unlimited scope for journal clubs in other fields to follow the example of #urojc and utilise online portals to revitalise the traditional journal club while fostering international relationships

Evaluating the effectiveness of an online journal club: experience from the International Urology Journal Club

The International Urology Journal Club attracts global participation; however, its effectiveness as an educational resource is undetermined.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.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.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.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.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

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. Combination therapy with any of docetaxel, abiraterone acetate, enzalutamide, or apalutamide provides a significant overall survival (OS) benefit when compared with androgen-deprivation therapy alone. We did not identify significant differences in OS between different combination therapies. Subtle differences between these options allow clinicians considerable flexibility when selecting options for individual patients