A critical analysis of deficiencies in the quality of information contained in prostate multiparametric MRI requests and reports

BACKGROUND

Multiparametric magnetic resonance imaging (mpMRI) has been increasingly recognised as an important tool in the diagnosis of prostate cancer. PI-RADSv2 guidelines recommend that important clinical information including prostate-specific antigen (PSA) levels, examination findings, and biopsy information should be included in mpMRI requests. PIRADS score and PSA density (PSAD) are both independent predictors for the presence of a clinically significant prostate cancer.

AIMS

This study aims to evaluate the quality of mpMRI requests and reports at our institution in accordance with these parameters.

METHODS

All prostate mpMRIs performed by radiology services in Galway University Hospital between 1st September 2019 and 1st March 2020 were reviewed. Exclusion criteria were applied. Requests and reports were analysed for the presence of the following parameters: PSA-results, examination findings, biopsy information, PI-RADS score, prostate volume, and PSAD.

RESULTS

A total of 586 mpMRIs were performed, and of these, 546 were included. PSA value was provided in 497 (91%) of requests, exam findings in 355 (65%), and biopsy information in 452 (82%). PIRADS score was included in 224 (41%) of reports, prostate volume in 178 (32.6%), and PSAD in 106 (19%).

CONCLUSIONS

Great variation in the quality of information contained in both requests and reports for prostate mpMRIs exists within our service. We aim to improve this by collaborating with our radiology colleagues to develop a proforma for requesting and reporting of mpMRIs for our radiology systems to ensure important clinical and radiological information is provided in future.

Assessment of the workload and financial burden of Bosniak IIF renal cyst surveillance in a tertiary referral hospital

Background

The Bosniak classification is a CT classification which stratifies renal cysts based on imaging appearances and therefore associated risk of malignancy. Bosniak IIf cysts are renal which have complex features and therefore require surveillance.

Aims

The aim of this study is to assess the economic and workload burden of diagnosing and following up Bosniak IIf cysts on the urology service in a tertiary hospital in the West of Ireland.

Methods

All patients with a diagnosis of Bosniak IIf renal cysts attending our urology service between 1st of January 2012 and 31st December 2020 were analysed. The following data were collected: number and modality of follow up scans, number of MDT discussions, number and type of outpatient appointments, surgical intervention, and length of follow up. Financial data were provided by the hospital finance department.

Results

One hundred and sixty-two patients were included. Total cost of follow up was €164,056, costing €1,012.7 per patient. Cost of outpatient visits was €77,850. Follow-up length ranged from 1 to 109 months, median follow up time 17.5 months. Overall cost of imaging was €74,518. There were a total of 80 MDT discussions at an overall cost of €11,688.

Conclusions

This study demonstrates that surveillance of patients with Bosniak IIf renal cysts represents a significant burden upon both radiology and urology services. Surveillance for these patients could be streamlined in the future through a number of initiatives such as virtual OPDs and dedicated MDTs.

Clinical Outcome of Retroperitoneal Lymph Node Dissection after Chemotherapy in Patients with Pure Embryonal Carcinoma in the Orchiectomy Specimen

OBJECTIVE

To determine the pathologic findings and clinical outcome of patients with pure embryonal carcinoma (EC) of the testis who were diagnosed with testis cancer from January 1989 to January 2013 who underwent an orchiectomy, cisplatin-based chemotherapy and a postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

METHODS

We compared those patients with 100% EC with those with mixed nonseminomatous germ cell tumor pathology who underwent a PC-RPLND.

RESULTS

Of 1105 patients who underwent a PC-RPLND, 145 had pure EC. Twenty-six percent of patients presented with metastatic disease outside the retroperitoneum. Patients with mixed histologies tended to have worse International Germ Cell Cancer Collaborative Group risk compared to those with EC at orchiectomy (P = .037). Histology at PC-RPLND revealed fibrosis or necrosis in 76%, mature teratoma in 19% and viable cancer in 4%. Over one-third of the patients had a residual mass of <1 cm prior to RPLND; of whom 15% harbored mature teratoma in PC-RPLND histology. The Kaplan-Meier estimated probability of recurrence at 5 years of follow-up was 3.1% (95% CI 1.2%, 8.0%) for EC histology, 7.3% lower than mixed histology. For cancer-specific mortality, the Kaplan-Meier estimated probability at 5 years was 4.6% (95% CI 3.3%, 6.3%) and 1.7% (95% CI 0.4%, 6.8%) for mixed and pure EC histologies, respectively.

CONCLUSION

Approximately 20% of patients with pure EC had teratoma at PC-RPLND. We have shown that those with a maximum node size of <1 cm should not be precluded from RPLND.

Identification of multipotent luminal progenitor cells in human prostate organoid cultures

The prostate gland consists of basal and luminal cells arranged as pseudostratified epithelium. In tissue recombination models, only basal cells reconstitute a complete prostate gland, yet murine lineage-tracing experiments show that luminal cells generate basal cells. It has remained challenging to address the molecular details of these transitions and whether they apply to humans, due to the lack of culture conditions that recapitulate prostate gland architecture. Here, we describe a 3D culture system that supports long-term expansion of primary mouse and human prostate organoids, composed of fully differentiated CK5+ basal and CK8+ luminal cells. Organoids are genetically stable, reconstitute prostate glands in recombination assays, and can be experimentally manipulated. Single human luminal and basal cells give rise to organoids, yet luminal-cell-derived organoids more closely resemble prostate glands. These data support a luminal multilineage progenitor cell model for prostate tissue and establish a robust, scalable system for mechanistic studies.

A patient reported outcome measure (PROM) assessing quality of care in the urology hospital outpatient setting

A prospective blind PROM (patient reported outcome measure) study performed in our urology department examined the outpatient-clinic experience. 104 questionnaires were completed. 23 patients (22%) felt the waiting times for appointments was excessive. 13 patients (13%) experienced difficulty in contacting administrative staff. 98 patients (94%) considered the waiting areas good but 31 patients (31%) considered lack of privacy an issue. Consultants saw 65 patients (63%). 62 patients (60%) expected to be seen by a consultant. 32 patients (31%) felt consultation with a different doctor on return visits was unsatisfactory. 76 patients (73%) "fully trusted" their doctors. 78 patients (75%) rated their visit excellent, 10 patients (10%) added comments. Despite frustration with waiting times, the experience of patients reflects a positive rapport and trust between patient and doctor.

Emergency management of acute urinary retention: results from an all-Ireland urologist practice survey

INTRODUCTION

Anecdotal evidence suggests that current service restrictions and operative cancellations are resulting in increased numbers of catheterized men in the community awaiting definitive management of their bladder outlet obstruction. We wished to analyse current admission policies and management strategies of acute urinary retention (AUR) secondary to benign prostatic enlargement (BPE) in Ireland.

METHODS

A total of 58 consultant urologists practicing in Ireland were sent a questionnaire about their management of AUR secondary to BPE. Data was collected relating to initial emergency management, timing of trial without catheter (TWOC), their use of alpha-blockers and follow-up policy.

RESULTS

Urethral catheterization is the initial management of choice by all 42 respondents. The patient is routinely admitted after catheterization by 20/42 consultants (48 %) and 22/42 (52 %) discharge the patient home with a urinary catheter (UC). TWOC is performed on day 2 in 11/20 (55 %) and on day 3 in 9/20 (45 %). In terms of individuals who admit patients presenting with AUR one failed TWOC is an indication for transurethral resection of the prostate in 10/20 (50 %), with 6/20 (30 %) performing a second TWOC on the same admission and 4/20 (20 %) discharging the patient for interval TURP. A total of 83 % of respondents, all of whom work in public institutions, expressed concerns relating to elective admission difficulties for definitive management of catheterized patients following AUR.

CONCLUSION

There is variation in the admission policy for AUR in Ireland. Elective admission and operative restrictions for catheterized patients following episodes of AUR are causing concern to the urologists in Ireland.

The impact of the National Treatment Purchase Fund on numbers of core urology training cases at University Hospital Galway

Since the National Treatment Purchase Fund (NTPF) scheme was introduced in 2002, public patients waiting longer than three months for investigations and treatment are offered care in the private medical sector. Our aim was to assess the impact of the NTPF scheme on the number of training cases performed at University Hospital Galway (UHG). The number and type of urological procedures performed in the private medical sector under the NTFP scheme in 2008 were obtained from the UHG waiting list office. The number of these procedures performed on public patients by trainees at UHG in 2008 was determined retrospectively by reviewing theatre records. A significant number of core urology procedures were performed in the private sector via the NTPF scheme. Cancer centre designation and implementation of the EWTD will also place further pressures on urological training opportunities in Ireland.

Effects of titanocene dichloride derivatives on prostate cancer cells, specifically DNA damage-induced apoptosis

BACKGROUND

While locally advanced prostate cancer is initially treatable with androgen ablation, eventually cells develop a castrate-resistant phenotype. Currently, there are no effective treatments for this form of the disease with Docetaxel only providing a small survival advantage. In this study, the effects of novel derivatives of titanocene dichloride on prostate cancer cell lines has been investigated.

METHODS

Cellular effects were assessed using the crystal violet assay and the clonogenic survival assay. Cell cycle and apoptosis were assessed by propidium iodide staining. DNA damage was analyzed by comet assay and Western analysis. DNA damage response inhibition was achieved by pre-incubation with an ATM/ATR inhibitor; CGK733 and DNA-PK inhibitor; DMNB.

RESULTS

These analogs caused a reduction in cell number. In particular titanocene Y and C had significant effects in all cell lines. A reduction in clonogenic survival was found in response to titanocene Y in three cell lines while the PC-3 cells exhibited increased resistance.Further analysis showed no effect on cell cycle however, the analogs were found to induce apoptosis in a dose-dependent manner in all cell lines. These analogs associate with DNA, induce DNA damage and a differential damage response. Inhibition of key regulators of this DNA damage response sensitized the PC-3 cell line to titanocene-induced apoptosis and significantly reduced the clonogenic capacity of the cells.

CONCLUSION

These results demonstrate the mechanism of action of these novel titanocene dichloride analogs and their potential use in castrate-independent advanced prostate cancer.

Ureterocolic fistula in the presence of a solitary kidney

Among the entero-urinary fistulae, those between the ureter and colon are rare. Most spontaneous ureterocolic fistulae are caused by urinary calculi. We report a case of a spontaneous ureterocolic fistula which occurred as a consequence of diverticular disease. This rare presentation was further complicated as it occurred in the presence of a solitary kidney. The patient underwent a laparoscopic defunctioning loop ileostomy and after 6 weeks underwent definitive surgical treatment of the ureterocolic fistula. We describe the presentation and management of this fistula and review the current literature.

Colonic perforation in Behçet’s syndrome

A 17-year-old gentleman was admitted to our hospital for headache, the differential diagnosis of which included Behçet’s syndrome (BS). He developed an acute abdomen and was found to have air under the diaphragm on erect chest X-ray. Subsequent laparotomy revealed multiple perforations throughout the colon. This report describes an unusual complication of Behcets syndrome occurring at the time of presentation and a review of the current literature of reported cases.

Can pre-assessment of patients with LUTS result in early discharge from urology clinic?

Waiting times for appointments for urological out-patients in Ireland and the U.K. can be excessively long. Nurse-led Lower Urinary Tract symptom (LUTs) pre-assessment clinics have been introduced to streamline patient care pathways. We examined whether a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit. A pilot study was undertaken whereby patients referred with LUTS were sent for pre-assessment prior to their out-patients appointment. 214 consecutive patients underwent pre-assessment. Of these, 39 (18%) patients were discharged following their first out-patient visit and 27 (13%) patients were discharged after a second attendance. A further 35 (16%) patients continued to attend but underwent no further investigations or treatment, and possibly should have been discharged earlier. Overall 46% of pre-assessed patients could have been discharged early from the urology clinic. In conclusion a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit.

Squamous cell carcinoma of the renal pelvis after curative retroperitoneal radiotherapy for seminoma

We report the case of a 71-year-old male who presented with squamous cell carcinoma of the renal pelvis in a solitary functioning kidney, 34 years after orchidectomy and adjuvant retroperitoneal radiotherapy for stage II seminoma. This rare second malignancy occurred in the radiation treatment field. Second malignancies are an uncommon but serious sequela of radiotherapy, with potential for significant health problems in patients with complete remission of primary disease. To our knowledge, this is the first report of squamous cell carcinoma of the renal pelvis occurring after radiation treatment.

Sentinel lymph node biopsy in breast cancer

The sentinel lymph node (SLN) procedure consists of identifying the first lymph node to receive lymphatic vessels draining a tumour. Sentinel node biopsy is a minimally invasive technique, resulting in lower morbidity than traditional axillary lymph node dissection. Screen detected breast cancers are associated with approximately a 20% incidence of axillary node involvement. Sentinel node biopsy represents a minimally invasive method of accurately staging these patients.