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Editorial: Ureteroscopy vs miniaturized percutaneous nephrolithotomy: what and who are we comparing?

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We read with interest the article by Zeng et al. [1] comparing super‐mini percutaneous nephrolithotomy (SMP) with ureteroscopy (URS) for treatment of 1–2‐cm lower pole renal calculi. In this prospective randomized controlled trial, SMP achieved significantly higher stone‐free rates (SFRs) than URS on first‐day KUB with ultrasonography (91.2% vs 71.2%) as well as on 3‐month CT (93.8% vs 82.5%). Haemoglobin drop and pain score were higher in the SMP group, although no blood transfusions were required in either group. We congratulate the authors for this well conducted multicentre study and for the comprehensive report of their results.

A few comments are worth making to aid correct interpretation of the data presented in this study. First, it remains unclear whether the superiority of SMP over URS in terms of SFR was inherent to operating techniques, or whether this might have been the result of superior skills and interest of the surgeons favouring SMP. Surgeons were (obviously) not blinded to operating technique, which could have led to a bias. No study available in the literature has yet questioned whether a surgeon might be better at one technique (SMP or URS) than another. Ultimately, results may differ if both techniques were compared between two expert centres dedicated to each technique, respectively.

Second, the study protocol allowed surgeons to leave fragments up to 2 mm at the end of URS procedures. Strikingly, ‘stone‐free’ status was defined as residual fragments ≤3 mm. This methodology may well have affected the results, as neither endoscopy, KUB, ultrasonography nor CT is precise enough to differentiate 2‐mm from 3‐mm fragments [2, 3]. Arguably, this might have contributed to a lower SFR in the URS group.

Third, the study protocol did not clearly describe indications and choices for auxiliary procedures. Consequently, four of seven SMP (57.1%) and 19 of 23 URS patients (82.6%) with ‘clinically significant’ residual fragments were offered auxiliary procedures such as SMP, shockwave lithotripsy or external physical vibration lithecbole. Remarkably, none of the patients in the URS arm was offered any second‐look intervention, while this was the case in the SMP group.

Fourth, achievements made in one country may not be transposable to others, as epidemiology of urinary stone disease, demographic characteristics, access to technologies and education differ from one country to another. This has been acknowledged by the authors, and it seems particularly important to recall the relatively low body mass index (BMI) found in this cohort (mean BMI < 25 kg/m2). Higher BMI values may arguably impact on outcomes of SMP.

We agree with the authors that both SMP and URS are safe and feasible treatment options for lower pole calculi. Importantly, expertise in percutaneous surgery is warranted for cases presenting impaired retrograde access. Nevertheless, in light of constant and rapid advances in the field of URS, it seems that superiority, if any, of percutaneous nephrolithotomy in terms of SFR is to be tackled by URS in the years to come. This is well illustrated in the present study where 1–2‐cm stones were treated by URS with a laser power range between 5 and 20 W within 52 min in 50% of all cases and within 75 min in 86.4% of all cases (calculations based on values from Table 2 [1]).

Notably, no consensus has been agreed for the definition of different sizing of percutaneous nephrolithotomy instruments [4]. In the present study, the authors refer to SMP as the use of maximal tract dilation and instrument size up to 14 F. The authors justify size reduction of instruments considering the possible reduced blood loss in favor of smaller access sheaths compared with conventional percutaneous nephrolithotomy [5]. Nevertheless, it should be recalled that whether conventional, mini, super‐mini or any other‐size percutaneous nephrolithotomy, these techniques all share the same fundamental methods of access to intrarenal cavities; therefore, their inherent potential risks and harms – particularly bleeding and iatrogenic organ injury – fundamentally remain the same. This might partly explain why solitary kidney was an exclusion criterion in this study. In contrast, URS respects the delineation of the urinary tract [6]. URS is therefore likely to maintain a superior safety profile, even if further efforts are made at reducing the size of percutaneous nephrolithotomy instruments in the years to come.

The authors’ statement that SMP is more effective than URS to treat 1–2‐cm lower pole calculi should be interpreted in the context of the above. We hope that our comments will aid the correct interpretation of the data presented in this study. We congratulate the authors for the originality of their study, and we encourage them to continue evaluating indications, efficiency and safety of SMP.

References

  1. Zeng G, Zhang T, Agrawal M et al. Super‐mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery for the treatment of 1‐2 cm lower‐pole renal calculi: an international multicentre randomised controlled trial. BJU Int 2018; 122: 1034–40
  2. Kishore TA, Pedro RN, Hinck B, Monga M. Estimation of size of distal ureteral stones: noncontrast CT scan versus actual size. Urology 2008; 72: 761–4
  5. Zhu W, Liu Y, Liu L et al. Minimally invasive versus standard percutaneous nephrolithotomy: a meta‐analysis. Urolithiasis 2015; 43: 563–70
  6. Giusti G, Proietti S, Villa L et al. Current standard technique for modern flexible ureteroscopy: tips and tricks. Eur Urol 2016; 70: 188–94

 

Article of the week: Multicentre international experience of 532‐nm laser PVP with GreenLight XPS in men with very large prostates

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, it should be this one.

Roger Valdivieso*, Pierre‐Alain Hueber*, Malek Meskawi*, Eric Belleville*, Khaled Ajib*, Franck Bruyere†, Alexis E. Te‡, Bilal Chughtai‡, Dean Elterman§, Vincent Misraiand Kevin C. Zorn*

 

*Division of Urology, Centre Hospitalier de l’Universite de Montreal (CHUM), Montreal, QC, Canada, †Department of Urology, CHU, Tours, France, ‡Department of Urology, Cornell University, New York, NY, USA, §Department of Urology, University of Toronto, Toronto, ON, Canada, and Department of Urology, Clinique Pasteur, Toulousse, France

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Abstract

Objectives

To describe peri‐operative results, functional outcomes and complications of laser photoselective vaporization, using the GreenLight system, of prostate glands ≥200 mL in volume.

Methods

Retrospective analysis of a prospectively maintained multicentre database was performed to select a subgroup of patients with very large prostates (volume ≥200 mL) treated with the GreenLight XPS laser. A subgroup of patients with prostate volumes 100–200 mL was used for comparison. International Prostate Symptom Score, maximum urinary flow rate, postvoid residual urine volume and prostate‐specific antigen levels were measured at 6, 12, 24, 36 and 48 months. Durability was evaluated using benign prostatic hyperplasia re‐treatment rate at 12, 24 and 36 months. Additionally, complications were recorded using Clavien–Dindo classification.

Results

A total of 33 patients (38%) had prostates ≥200 mL. Baseline characteristics were similar between patients with prostates ≥200 mL and those with prostates 100–200 mL. Patients with very large prostates (≥200 mL) had longer operating times (129 vs 93 min), less energy delivered, a greater number of fibres used (3 vs 2) and a higher conversion rate to transurethral resection of the prostate (16% vs 4%). In terms of complications and functional outcomes, we did not find any differences between the groups. Retreatment rate was also comparable.

Conclusions

Our results show that PVP GreenLight XPS‐180W is an acceptable technique for very large prostates (≥200 mL); however, operating times, energy delivery, fibres used and conversion to TURP are a concern in this particular subgroup. This should be used for patient counselling and surgery planning.

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Article of the week: Does the introduction of prostate multi-parametric MRI into the AS protocol for localized PCa improve patient re-classification?

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

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

Richard J. Bryant*† , Bob Yang* , Yiannis Philippou*, Karla Lam*, Maureen Obiakor*, Jennifer Ayers*, Virginia Chiocchia†‡, Fergus Gleeson§, Ruth MacPherson§, Clare Verrill†¶, Prasanna Sooriakumaran†**, Freddie C. Hamdy*† and Simon F. Brewster*

*Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, †Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK, ‡National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK, §Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK, and **Department of Uro-Oncology, University College London Hospital NHS Foundation Trust, London, UK

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Abstract

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.

Conclusion

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.

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Residents’ podcast: Urinary, bowel and sexual health in older men from Northern Ireland

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Maria Uloko is a Urology Resident at the University of Minnesota Hospital and Giulia Lane is a Female Pelvic Medicine and Reconstructive Surgery Fellow at the University of Michigan.

In this podcast they discuss the following BJUI Article of the Week:

Urinary, bowel and sexual health in older men from Northern Ireland

David W. Donnelly*, Conan Donnelly†, Therese Kearney*, David Weller‡, Linda Sharp§, Amy Downing¶, Sarah Wilding¶, PennyWright¶, Paul Kind**, James W.F. Catto††, William R. Cross‡‡, Malcolm D. Mason§§, Eilis McCaughan¶¶, Richard Wagland***, Eila Watson†††, Rebecca Mottram¶, Majorie Allen, Hugh Butcher‡‡‡, Luke Hounsome§§§, Peter Selby, Dyfed Huws¶¶¶, David H. Brewster****, EmmaMcNair****, Carol Rivas††††, Johana Nayoan***, Mike Horton‡‡‡‡, Lauren Matheson†††, Adam W. Glaser and Anna Gavin*

*Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Belfast, UK, †National Cancer Registry Ireland, Cork, Ireland, ‡Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK, §Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK, Leeds Institute of Cancer and Pathology/Leeds Institute of Data Analytics, University of Leeds, Leeds, UK, **Institute of Health Sciences, University of Leeds, Leeds, UK, ††Academic Urology Unit, University of Sheffield, Sheffield, UK, ‡‡Department of Urology, St James’s University Hospital, Leeds, UK, §§Division of Cancer and Genetics, School of Medicine, Velindre Hospital, Cardiff University, Cardiff, UK, ¶¶Institute of Nursing and Health Research, Ulster University, Coleraine, UK, ***Faculty of Health Sciences, University of Southampton, Southampton, UK, †††Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK, ‡‡‡Yorkshire Cancer Patient Forum, c/o Strategic Clinical Network and Senate, Yorkshire and The Humber, Harrogate, UK, §§§National Cancer Registration and Analysis Service, Public Health England, Bristol, UK, ¶¶¶Welsh Cancer Intelligence and Surveillance Unit, Cardiff, UK, ****Information Services Division, NHS National Services Scotland, Edinburgh, UK, ††††Department of Social Science, UCL Institute of Education, University College London, London, UK, and ‡‡‡‡Psychometric Laboratory for Health Sciences, Academic Department of Rehabilitation Medicine, University of Leeds, Leeds, UK

Read the full article

Abstract

 Objectives

To provide data on the prevalence of urinary, bowel and sexual dysfunction in Northern Ireland (NI), to act as a baseline for studies of prostate cancer outcomes and to aid service provision within the general population.

Subjects and Methods

A cross‐sectional postal survey of 10 000 men aged ≥40 years in NI was conducted and age‐matched to the distribution of men living with prostate cancer. The EuroQoL five Dimensions five Levels (EQ‐5D‐5L) and 26‐item Expanded Prostate Cancer Composite (EPIC‐26) instruments were used to enable comparisons with prostate cancer outcome studies. Whilst representative of the prostate cancer survivor population, the age‐distribution of the sample differs from the general population, thus data were generalised to the NI population by excluding those aged 40–59 years and applying survey weights. Results are presented as proportions reporting problems along with mean composite scores, with differences by respondent characteristics assessed using chi‐squared tests, analysis of variance, and multivariable log‐linear regression.

Results

Amongst men aged ≥60 years, 32.8% reported sexual dysfunction, 9.3% urinary dysfunction, and 6.5% bowel dysfunction. In all, 38.1% reported at least one problem and 2.1% all three. Worse outcome was associated with increasing number of long‐term conditions, low physical activity, and higher body mass index (BMI). Urinary incontinence, urinary irritation/obstruction, and sexual dysfunction increased with age; whilst urinary incontinence, bowel, and sexual dysfunction were more common among the unemployed.

Conclusion

These data provide an insight into sensitive issues seldom reported by elderly men, which result in poor general health, but could be addressed given adequate service provision. The relationship between these problems, raised BMI and low physical activity offers the prospect of additional health gain by addressing public health issues such as obesity. The results provide essential contemporary population data against which outcomes for those living with prostate cancer can be compared. They will facilitate greater understanding of the true impact of specific treatments such as surgical interventions, pelvic radiation or androgen‐deprivation therapy.

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Editorial: Multi-parametric MRI: an important tool to improve risk stratification for active surveillance in prostate cancer

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Multiparametric MRI (mpMRI) has become an important adjunct in the management of localized prostate cancer (PCa), particularly in the active surveillance (AS) setting. Current guideline recommendations [1,2] have recommended incorporation of mpMRI into AS protocols to improve patient stratification and reclassification.

Bryant et al. [3], based on updated National Institute of Health and Care Excellence (NICE) guidelines [1], report on the effect of mpMRI incorporation into their institution’s AS protocols, specifically focusing on the time to treatment and number of biopsies required to trigger treatment. In 2014, they replaced protocol‐driven biannual prostate biopsies (PBs) with mpMRI ± cognitive targeted biopsy and systematic biopsy (TB). With a median follow‐up of 2.4 years, they found that more men who underwent TB progressed to treatment than men who underwent PB alone (44% vs 37%; P = 0.003). The median number of biopsies (beyond the original diagnostic biopsy) required to trigger intervention was 1.55. Based on these results, the authors conclude that mpMRI‐driven TB increases reclassification compared with protocol‐driven PB.

This is consistent with increasing evidence that mpMRI enhances, and sometimes, exceeds detection of clinically significant PCa over TRUS‐guided prostate biopsy alone. The PROMIS study [4], a multicentre paired validation study that compared mpMRI to TRUS‐guided biopsy in the diagnostic setting, found that mpMRI had better sensitivity (93% vs 43%; P < 0.001) and negative predictive value (89% vs 74%; P < 0.001) than TRUS‐guided biopsy in detecting clinically significant cancer (defined as Gleason grade ≥4 + 3). While the concerns about foregoing a systematic biopsy at the time of targeted biopsy in that study were warranted, there was consensus that prebiopsy mpMRI increased the yield for clinically significant PCa.

In the AS setting, unfortunately, randomized data are lacking; however, retrospective series and systematic reviews provide some guidance. In a systematic review, Schoots et al. [5] found that a positive mpMRI in the AS setting was associated with a higher risk of upgrading at the time of radical prostatectomy and a higher risk of reclassification at the time of confirmatory biopsy. Yet, a negative mpMRI did not preclude reclassification and upgrading, indicating the continued need for systematic biopsy. Recabal et al. [6] confirmed these conclusions in their retrospective assessment of an institutionally maintained prospective dataset. While MRI‐targeted biopsies detected higher grade cancer in 23% of men, they missed higher grade clinically significant cancers in 17%, 12% and 10% of patients with mpMRI scores of 3, 4 and 5, respectively. This suggests that both targeted and systematic biopsy should be used for the optimal detection of clinically significant PCa in men on AS.

The present study by Bryant et al. [3] reaffirms the value of mpMRI in the AS paradigm. Yet, some concerns about their study cohort and methodology should be noted. First, as the authors clearly note as a limitation, despite completing a targeted and systematic biopsy, all the samples were sent as a single specimen, precluding the ability to distinguish between targeted biopsy and systematic biopsy cores. As the absolute difference in the rate of progression to treatment between the PB and TB arms was only 7%, it is uncertain how much of that was attributable to the addition of targeted biopsy alone.

Additionally, in a closer analysis of their study population, it should be noted that 35% of the patients had Gleason Grade Group 2 disease or higher at the time of inclusion, representing a higher‐risk AS patient population than guideline recommendations. This may account for the higher rate of progression to treatment in this study cohort independent of grade progression – 24% of patients progressed to treatment based on PSA progression alone and an additional 10% were based on mpMRI findings alone.

Lastly, the median number of biopsies required to trigger intervention was 1.55 and, for the majority of patients, this was just one additional biopsy beyond the original diagnostic biopsy. Guideline recommendations indicate the importance of a confirmatory biopsy to exclude Gleason sampling error [2]; however, by definition, many of these patients were essentially upstaged or redirected to active treatment after a confirmatory biopsy. With 59% of the entire AS population never receiving a confirmatory biopsy beyond their original diagnostic biopsy and many progressing to treatment after a confirmatory biopsy, this study population may not reflect a well‐selected low‐risk PCa patient population for AS.

Despite these limitations, the work by Bryant et al. [3] adds to the growing body of evidence supporting the use of mpMRI‐targeted biopsies in addition to systematic biopsy to more accurately risk stratify men for AS, particularly at the time of diagnosis. It remains unknown how we can use mpMRI to individually tailor surveillance strategies or if mpMRI may ultimately replace surveillance biopsies over time.

References

  1. Graham J, Kirkbride P, Cann K, Hasler E, Prettyjohns M. Prostate cancer: summary of updated NICE guidance. BMJ (Clinical research ed.). 2014; 348: f7524
  2. Mottet N, Bellmunt J, Bolla M et al. EAU‐ESTRO‐SIOG Guidelines on Prostate Cancer. Part 1: screening, diagnosis, and local treatment with curative intent. Eur Urol 2017; 71: 618–29

 

Editorial: Contemporary quality‐of‐life scores provide a key foundation for high‐quality cancer research

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Prostate cancer is the most common male malignancy in many countries, including the UK/Northern Ireland. Given excellent oncological outcomes for appropriately treated localised cancer, there is an increasing focus on understanding the quality‐of‐life implications of different treatment options.

As Donnelly et al. [1] emphasise, contemporary cohorts of untreated men can provide useful comparisons for inferring the impact of treatment. Specifically, updated population‐level observations of urinary, bowel, and sexual dysfunction are needed to provide a baseline for such discussions. Surveys should focus on particular populations (e.g. geographic), utilise prostate cancer‐specific questionnaires, and ensure age‐matched cohorts. Such baseline characteristics are essential to teasing apart the impact of prostate cancer and its treatment from ageing and comorbidities.

Donnelly et al. [1] sampled 10 000 men in Northern Ireland aged >40 years, using the EuroQoL five Dimensions five Levels (EQ‐5D‐5L) survey to assess a general health baseline and Extended Prostate Cancer Composite (EPIC) questionnaire to determine bladder, bowel, and sexual function more specifically. In all, 2 955 men responded, although ultimately only men aged >60 years were analysed to better match the age distribution of patients with prostate cancer. Strikingly, they found that nearly two out of five men reported at least one urinary, bowel, or sexual issue. A third of men reported some degree of urinary leakage, 26% had some degree of bowel problems, and as much as 57.9% of respondents had some problem with sexual function [1].

Nearly two decades ago, Litwin [2] published a health‐related quality of life control sample of older men in the USA without prostate cancer using the University of California Los Angeles Prostate Cancer Index (UCLA‐PCI, a precursor to EPIC). He found ageing subjects had diminished urinary continence, bowel function, and sexual potency, with similar rates to the Northern Ireland study: a third reported urinary leakage, a third had bowel complaints, and nearly two‐thirds claimed to have erectile dysfunction (ED).

In contrast, patient‐reported outcomes in the Prostate Testing for Cancer and Treatment (ProtecT) trial showed low levels of urinary incontinence and bowel symptoms, and one‐third of men had sexual dysfunction [3]. The difference here in ED when compared to Donnelly et al. [1] may be attributed to the age distribution differences between the cohorts, as ProtecT included men aged 50–69 years and the Northern Ireland group looked only at men aged >60 years. This highlights the importance of ensuring age‐matched cohorts when using population‐based surveys as baselines for assessment counselling.

Furthermore, Resnick et al. [4] evaluated the change in patient‐reported urinary incontinence and ED over time in two cohorts of patients enrolled almost 20 years apart. They compared patients enrolled in 1994–1995 in the Prostate Cancer Outcomes Study (PCOS) vs those enrolled in 2011–2012 in the Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study. Men in PCOS were surveyed using UCLA‐PCI, and those in CEASAR completed EPIC‐26. They found that self‐reported urinary incontinence was more common in CEASAR than in PCOS (7.7% vs 4.7%), as was ED (44.7% vs 24%). These differences could be due to rising rates of comorbidities associated with ED and urinary incontinence or they may reflect an increase in social awareness and disclosure of these issues.

Taken together, these self‐reported rates of pretreatment urinary and sexual function underscore the potential for significant variation in reporting of patient quality‐of‐life outcomes in prostate cancer.

This does not mean that patient‐reported outcomes should be ignored. Rather the takeaway is that we must invest in tools to ensure that reporting is appropriate, standardised, and accurate [5]. And regardless of whether these data are collected prospectively, or retrospectively, it is vital to use appropriate statistical methods and scientific principles to account for bias and to ensure that causal inferences are valid [6].

As prostate cancer survival and mortality rates improve, patients and clinicians must weigh treatment‐specific short‐ and long‐term effects on quality of life. Patient‐reported outcome measures are vital to assessing these major impacts. Contemporary, population‐based cohorts such as that provided by Donnelly et al. [1], provide a key tool for better interpreting and understanding these results.

References

  1. Donnelly DW, Donnelly C, Kearney T et al. Urinary, bowel and sexual health in older men from Northern Ireland. BJU Int 2018; 122: 845–57
  2. Litwin MS. Health related quality of life in older men without prostate cancer. J Urol 1999; 161: 1180–4

 

 

Article of the week: Urinary, bowel and sexual health in older men from Northern Ireland

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a video produced by the authors, and a podcast created by our Resident podcasters Giulia Lane and Maria Uloko.

If you only have time to read one article this week, it should be this one.

Urinary, bowel and sexual health in older men from Northern Ireland

David W. Donnelly*, Conan Donnelly†, Therese Kearney*, David Weller‡, Linda Sharp§, Amy Downing¶, Sarah Wilding¶, PennyWright¶, Paul Kind**, James W.F. Catto††, William R. Cross‡‡, Malcolm D. Mason§§, Eilis McCaughan¶¶, Richard Wagland***, Eila Watson†††, Rebecca Mottram¶, Majorie Allen, Hugh Butcher‡‡‡, Luke Hounsome§§§, Peter Selby, Dyfed Huws¶¶¶, David H. Brewster****, EmmaMcNair****, Carol Rivas††††, Johana Nayoan***, Mike Horton‡‡‡‡, Lauren Matheson†††, Adam W. Glaser and Anna Gavin*

*Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Belfast, UK, †National Cancer Registry Ireland, Cork, Ireland, ‡Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK, §Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK, Leeds Institute of Cancer and Pathology/Leeds Institute of Data Analytics, University of Leeds, Leeds, UK, **Institute of Health Sciences, University of Leeds, Leeds, UK, ††Academic Urology Unit, University of Sheffield, Sheffield, UK, ‡‡Department of Urology, St James’s University Hospital, Leeds, UK, §§Division of Cancer and Genetics, School of Medicine, Velindre Hospital, Cardiff University, Cardiff, UK, ¶¶Institute of Nursing and Health Research, Ulster University, Coleraine, UK, ***Faculty of Health Sciences, University of Southampton, Southampton, UK, †††Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK, ‡‡‡Yorkshire Cancer Patient Forum, c/o Strategic Clinical Network and Senate, Yorkshire and The Humber, Harrogate, UK, §§§National Cancer Registration and Analysis Service, Public Health England, Bristol, UK, ¶¶¶Welsh Cancer Intelligence and Surveillance Unit, Cardiff, UK, ****Information Services Division, NHS National Services Scotland, Edinburgh, UK, ††††Department of Social Science, UCL Institute of Education, University College London, London, UK, and ‡‡‡‡Psychometric Laboratory for Health Sciences, Academic Department of Rehabilitation Medicine, University of Leeds, Leeds, UK. Check out the latest carbofix reviews.

Read the full article

Abstract

 Objectives

To provide data on the prevalence of urinary, bowel and sexual dysfunction in Northern Ireland (NI), to act as a baseline for studies of prostate cancer outcomes and to aid service provision within the general population.

Subjects and Methods

A cross‐sectional postal survey of 10 000 men aged ≥40 years in NI was conducted and age‐matched to the distribution of men living with prostate cancer. The EuroQoL five Dimensions five Levels (EQ‐5D‐5L) and 26‐item Expanded Prostate Cancer Composite (EPIC‐26) instruments were used to enable comparisons with prostate cancer outcome studies. Whilst representative of the prostate cancer survivor population, the age‐distribution of the sample differs from the general population, thus data were generalised to the NI population by excluding those aged 40–59 years and applying survey weights. Results are presented as proportions reporting problems along with mean composite scores, with differences by respondent characteristics assessed using chi‐squared tests, analysis of variance, and multivariable log‐linear regression. Prevent most unhealthy conditions after reading these biofit reviews.

Results

Amongst men aged ≥60 years, 32.8% reported sexual dysfunction, 9.3% urinary dysfunction, and 6.5% bowel dysfunction. In all, 38.1% reported at least one problem and 2.1% all three. Worse outcome was associated with increasing number of long‐term conditions, low physical activity, and higher body mass index (BMI). Urinary incontinence, urinary irritation/obstruction, and sexual dysfunction increased with age; whilst urinary incontinence, bowel, and sexual dysfunction were more common among the unemployed.

Conclusion

These data provide an insight into sensitive issues seldom reported by elderly men, which result in poor general health, but could be addressed given adequate service provision. The relationship between these problems, raised BMI and low physical activity offers the prospect of additional health gain by addressing public health issues such as obesity. The results provide essential contemporary population data against which outcomes for those living with prostate cancer can be compared. They will facilitate greater understanding of the true impact of specific treatments such as surgical interventions, pelvic radiation or androgen‐deprivation therapy.

Read more Articles of the week

 

Video: Urinary, bowel and sexual health in older men

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Urinary, bowel and sexual health in older men from Northern Ireland

Read the full article

Abstract

Objectives

To provide data on the prevalence of urinary, bowel and sexual dysfunction in Northern Ireland (NI), to act as a baseline for studies of prostate cancer outcomes and to aid service provision within the general population. Prevent most unhealthy conditions with carbofix.

Subjects and Methods

A cross‐sectional postal survey of 10 000 men aged ≥40 years in NI was conducted and age‐matched to the distribution of men living with prostate cancer. The EuroQoL five Dimensions five Levels (EQ‐5D‐5L) and 26‐item Expanded Prostate Cancer Composite (EPIC‐26) instruments were used to enable comparisons with prostate cancer outcome studies. Whilst representative of the prostate cancer survivor population, the age‐distribution of the sample differs from the general population, thus data were generalised to the NI population by excluding those aged 40–59 years and applying survey weights. Results are presented as proportions reporting problems along with mean composite scores, with differences by respondent characteristics assessed using chi‐squared tests, analysis of variance, and multivariable log‐linear regression. Check out the latest gluconite reviews.

Results

Amongst men aged ≥60 years, 32.8% reported sexual dysfunction, 9.3% urinary dysfunction, and 6.5% bowel dysfunction. In all, 38.1% reported at least one problem and 2.1% all three. Worse outcome was associated with increasing number of long‐term conditions, low physical activity, and higher body mass index (BMI). Urinary incontinence, urinary irritation/obstruction, and sexual dysfunction increased with age; whilst urinary incontinence, bowel, and sexual dysfunction were more common among the unemployed.

Conclusion

These data provide an insight into sensitive issues seldom reported by elderly men, which result in poor general health, but could be addressed given adequate service provision. The relationship between these problems, raised BMI and low physical activity offers the prospect of additional health gain by addressing public health issues such as obesity. The results provide essential contemporary population data against which outcomes for those living with prostate cancer can be compared. They will facilitate greater understanding of the true impact of specific treatments such as surgical interventions, pelvic radiation or androgen‐deprivation therapy.

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Article of the month: The US opioid epidemic

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Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The United States opioid epidemic: a review of the surgeon’s contribution to it and health policy initiatives

Katherine Theisen, Bruce Jacobs, Liam Macleod and Benjamin Davies
Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
 
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Abstract

Visual abstract created by Abdullatif Aydın and Rebecca Fisher

Opioid abuse and addiction is causing widespread devastation in communities across the USA and resulting in significant strain on our healthcare system. There is increasing evidence that prescribers are at least partly responsible for the opioid crisis because of overprescribing, a practice that developed from changes in policy and reimbursement structures. Surgeons, specifically, have been subject to scrutiny as ‘adequate treatment’ of post‐surgical pain is poorly defined and data suggest that many patients receive much larger opioid prescriptions than needed. The consequences of overprescribing include addiction and misuse, dispersion of opioids into the community, and possible potentiation of illicit drug/heroin use. Several solutions to this crisis are currently being enacted with variable success, including Prescription Drug Monitoring Programmes, policy‐level interventions aimed to de‐incentivize overprescribing, limiting opioid exposures through Enhanced Recovery After Surgery protocols, and the novel idea of creating surgery‐ and/or procedure‐specific prescribing guidelines. This problem is likely to require not one, but several potential solutions to reverse its trajectory. It is critical, however, that we as physicians and prescribers find a way to stop the needless overprescribing while still treating postoperative pain appropriately.

 

 

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Editorial: The opioid epidemic: a wake‐up call for us all

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The article in this issue of BJUI by Theisen et al. [1] is a timely reminder of the duty of all prescribers (including surgeons) to be mindful of the potential unintended consequences and off‐target effects of medicines.

Although some of the factors that have led to serious opioid‐related problems are particularly related to the US setting, we in Europe and other continents should not be complacent [2, 3].

The US Department of Health and Human Services (HHS) stated that, in 2016, opioid deaths had risen to > 42 000 deaths, of which an estimated 40% involved a prescription opioid [4].

The underlying reasons for this opioid epidemic are multiple and complex.

The prevalence of pain in the population is high, as are patients expectations and demands for treatment. The ageing population, living with multiple painful conditions, including cancer survivors and patients with persisting post‐surgery chronic pain, has further increased the demand for analgesics.

Meanwhile, the WHO’s drive over the last 30 years to eradicate ‘opiophobia’ and ensure that opioids are available for cancer pain, together with the advent of potent prolonged‐release opioid formulations, led to a transfer of this therapeutic experience to non‐cancer pain. A few questioned the wisdom of this strategy, but reassurance was drawn from an 11‐line letter in the New England Journal of Medicine in 1980, oft cited and misquoted as evidence that addiction was rare with long‐term opioids [5]. Subsequently, the journal has added a note warning readers that ‘the letter has been heavily and uncritically cited by sources using it to suggest opioids are not addictive.’ In fact, the authors surveyed the files of inpatients who were administered predominantly short‐term opioids in hospital, including patients who had only received one dose, and concluded that in this population, development of new addiction was rare.

Add to these factors, the well‐intentioned drive to assess and treat pain with initiatives such as ‘Pain – the fifth vital sign’, and pharmaceutical company promotion of their new opioid formulations, and the scene was set for greatly increased opioid initiation, escalation of dosage and repeat prescribing without regular patient review. In addition to these factors, it was also identified that a proportion of patients continue to receive opioids long after their surgery [6].

By 2017, year‐on‐year increases in long‐term opioid prescribing compounded by the diversion of the medicines, illicit manufacture and importing of compounds, such as fentanyl analogues, culminated in the staggering US mortality data and the HHS declaring a public health emergency with a five‐point strategy to combat the opioid crisis.

What strategies can we adopt during and after surgery? Better multimodal acute inpatient analgesia and working closely with our acute pain colleagues will surely assist in achieving less need for subsequent opioid prescribing on discharge. Using enhanced recovery pathways encourages the use of opioid‐sparing local and regional anaesthetic blocks, together with simple analgesia rather than prolonged use of high‐dose opioids. The goal must be to discharge patients on less potent analgesics and for a shorter duration. The analogy is with antibiotic prescribing where only a limited supply is dispensed. We need to develop pain discharge plans which can be communicated to the primary care physician incorporating tapering, patient education and emphasis on avoiding the repeat prescribing of opioids. Where pain persists, the patient should be referred back to the surgical or pain management team sooner in order to review progress. We should be wary of prescribing modified‐release preparations of a drug such as morphine or oxycodone because these contain a high dose, which can be extracted from the slow‐release preparation for abuse purposes. Similarly, the use of opioid‐based patches encourages extended use of opioid drugs, sometimes without a full understanding of the hourly or daily morphine equivalent dosage. Looking forward, there is the promise of new non‐opioid analgesics for chronic pain on the horizon, in particular long‐acting, prolonged‐release local anaesthetics for use in the wound or for nerve blocks. We need to adopt strategies for the regular review of pain medication rather than the all too often ‘automatic’ repeat prescription.

In urology, we have seen a significant reduction in the use of opioids on discharge through the use of less invasive, endoscopic/robotic techniques, local anaesthetic blocks such as the transversus abdominis block, which is so valuable in abdominal procedures, wound local anaesthetic infusion catheters and the use of regular simple analgesics given by the clock, providing excellent opioid‐sparing background analgesia.

Less opioid drug prescribing in the community is the way forward as Theisen et al. describe. As peri‐operative physicians, we must respond to this challenge if we are to avert a similar crisis to that seen in the USA. In peri‐operative practice, responsible and appropriate opioid‐prescribing remains an essential part of good pain management, while we strive to reduce both dose and duration of therapy. These strategies serve both wider society and the individual patient, for whom the benefit is reduced dose‐dependent opioid side effects. In the modern era where specialist advice is available through multidisciplinary team working, we need to minimize repeat prescribing and ensure that a specific opioid tapering plan is in place. The latter relies on good communication, teamwork and partnership, the essential ‘Domain 3’ of General Medical Council Good Medical Practice [7].

References

  1. Theisen K, Jacobs B, Macleod L, Davies B. The United States opioid epidemic: a review of the surgeon’s contribution and health policy initiatives. BJU Int 2018; 122: 754–9
  2. Stannard C. Opioids in the UK: what’s the problem? BMJ 2013; 347: f5108
  3. Weisberg DF, Becker WC, Fiellin DA, Stannard C. Prescription opioid misuse in the United States and the United Kingdom: cautionary lessons. Int J Drug Policy 2014; 358: 1124–30
  4. US Department of Health and Human Services. What is the U.S. Opioid Epidemic? Available at: https://www.hhs.gov/opioids/about-the-epidemic/index.html. Accessed October 2018
  5. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980; 302: 123
  6. Clarke H, Soneji N, Ko TD, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014; 348: g1251
  7. GMC Good Medical Practice, 2013. Available at: www.gmc-uk.org/guidance Accessed October 2018

 

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