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Background and objectives Erectile dysfunction (ED) is a multifactorial disease associated with many medical co-morbidities and risk factors commonly encountered in primary care. Initial management includes lifestyle changes and the treatment of any identifiable conditions. Guidelines exist recommending the assessment and management of sufferers with clear indications for referral to secondary care. With the outbreak of COVID-19, non-urgent medical services, including ED, were suspended, creating a significant waiting list for these patients. The aim of this study was to review the management of men in both primary and secondary care who had been referred to a dedicated ED service. Materials and methods A retrospective review of men referred to secondary care between June 2018 and April 2021 with ED was undertaken, reviewing whether the guidelines published by the National Institute for Health and Care Excellence (NICE) and GP Notebook for the assessment, initial treatment, and referral were followed by the primary care clinician. A secondary aim was to record the outcome of those men after review in a secondary care dedicated ED clinic. Results One hundred and forty-eight men were reviewed in the ED clinic, with 55 men (37.2%) requiring an intervention that was appropriate to have been delivered in primary care. The majority of those (76.3%) were successfully managed with a phosphodiesterase inhibitor. Of those treated in secondary care, almost 60% required a second-line therapy, such as a vacuum device or the administration of alprostadil, with 14 men (15%) necessitating the surgical implantation of a penile prosthesis. Conclusion With a rise in both the prevalence and incidence of ED, primary care physicians have a pivotal role in the screening and initial assessment of patients with ED, with evidence suggesting that a significant proportion can be successfully managed in this setting.
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Background Penile cancer is a rare malignancy usually requiring surgery to achieve oncological control of the primary tumour but often at the expense of functional length. The presenting stage of the primary is a crucial factor in determining the most appropriate surgical procedure. Accurate preoperative staging is essential, and current modalities include clinical and radiological assessment. Clinical staging can, however, be hampered by patient body habitus and unreliable for more advanced T4 tumours, whereas radiological staging allows for more detailed identification of tissue planes and tumour involvement. There is no clear consensus on the preferred imaging technique, although, in the current European Association of Urology penile cancer guidelines, MRI is recommended with the use of ultrasound when MRI is not available. It was recommended that having the penis in an erect state by the administration of intra-cavernosal prostaglandin gave a more detailed picture enabling a greater predictor of corporal involvement. Recent studies have, however, suggested that there may be no such advantage. Methodology A retrospective review was conducted of all patients who underwent surgery for penile cancer comparing the preoperative MRI stage with the final pathological stage between July 2009 and June 2023. In addition to the MRI, patients were given an intra-cavernosal injection of prostaglandin E1 to induce tumescence unless otherwise indicated. All imaging was reported by a single consultant uro-radiologist with surgery undertaken by a single surgeon and pathology reviewed through the supra-regional penile multidisciplinary team. Results A total of 136 penile cancer patients were included in the review. Within this cohort, 98 patients had an MRI without intra-cavernosal prostaglandin and the number who had Ta, T1, T2, T3 and T4 histopathological stages was 3, 31, 45, 18, and 1, respectively. The preoperative MRI stage had a low agreement with the final histological stage for early tumours, with sensitivities and specificity of 35% and 97% for T1 and 56% and 80% for T2, respectively. Sensitivity and specificity increased for cavernosal involvement at 83% and 95%, respectively. In addition, a further 38 patients had an MRI in conjunction with an injection of prostaglandin E1 which failed to show any diagnostic improvement in sensitivity or specificity in the preoperative MRI stage. Conclusions The use of MRI as a preoperative modality for staging penile cancer performs best for identifying tumour involvement of the cavernosal bodies. Performing the MRI with the penis erect with the use of an intra-cavernosal injection did not offer any additional benefit in accurately staging penile cancer.
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Introduction The urology multidisciplinary team meeting (MDT) is the key weekly meeting that allows the opportunity to review results and discuss management plans for all urological cancers within a department. As populations age and cancer detection and management improve, the demand for the MDT will increase. We conducted a collaborative transregional study within the UK to evaluate the current workload on the urology MDT. Methods The study was divided into two parts: a multicenter retrospective audit and a snapshot survey. Three UK hospitals in Birmingham, Liverpool, and Cardiff were recruited into the multicenter study. Each hospital provided full MDT lists for all weekly meetings between August 2017 and 2022. Retrospective data gathered included the number of patients discussed per week, the average age of patients per week, the time allocated to their weekly MDT, and the total number of consultants in the department. The second part of the study involved the distribution of an online questionnaire to urologists across the UK to obtain a snapshot picture with the above parameters. Results Snapshot data from 34 different UK hospitals showed MDT length ranged from 1-6 hours, patients discussed ranged from 10-90 per week, and the maximum average discussion time was 3.8 minutes per case. Furthermore, 76% (N = 28/37) of respondents said unnecessary cases were discussed. Varied suggestions were provided on how the MDT could be improved. Multicenter five-year data showed a rise in mean total numbers of patients discussed per week in all centers: a 34.8% increase in Birmingham (from 34.5 patients to 46.5 patients), a 23.5% increase in Liverpool (27.2 patients to 33.6 patients), and a 38.8% increase in Cardiff (22.7 patients to 31.5 patients). Hours per meeting were Birmingham (2), Liverpool (3), and Cardiff (4), which meant the average minutes per patient discussion were Birmingham (2.6), Liverpool (5.4), and Cardiff (7.6). Conclusion There is a rapidly rising trend across UK regions for the number of patients being discussed in the urology MDT meeting. The MDT structure and function across the country are highly variable. There is consensus that the MDT discusses cases that are unnecessary, and this has been recognized for many years. Widespread implementation of the latest MDT management guidelines is urgently required to ensure MDT meetings are able to function effectively and efficiently into the future.
