Evaluation of Patients Referred for Abnormal Digital Rectal Examination With Normal Prostate-Specific Antigen on Best Timed Pathway for Prostate Cancer.

Introduction Currently, there is no recommendation for adjustments to the Best Timed Pathway for Prostate cancer (BTiPP) depending on whether the referral is for raised prostate-specific antigen (PSA) or malignant-feeling prostate on digital rectal examination (DRE). Therefore, all patients undergo MRI scanning. We aim to establish if patients with abnormal DRE only (without raised PSA) should have an adjusted pathway by comparing the biopsy rate and diagnostic yield after an MRI scan. Methods All BTiPP 2021 referral patient notes were reviewed. The patients were categorized into the aDRE group (abnormal DRE with normal PSA) or the rPSA group (raised PSA with or without abnormal DRE). Data and results for MRI and prostate biopsy were evaluated. Diagnostic yield was defined as the percentage of patients who underwent an MRI, who were diagnosed with biopsy-proven cancer. Results 68.5% (74/108) and 70.9% (282/398) of patients underwent upfront MRI in the aDRE and rPSA groups, respectively. Following MRI, the biopsy rate (28.4% (21/74) vs. 42.9% (121/282) (p=0.02)) and the biopsy-proven diagnostic yield (20.3% (15/74) vs. 36.9% (104/282) (p<0.01)) were both significantly lower in the aDRE group. 58% (43/74) of patients in the aDRE group had no posterior lesions on MRI. Only 6.7% (1/15) of biopsy-proven cancers in the aDRE group were solely anterior. Conclusions After MRI, the biopsy rate and diagnostic yield were significantly lower in the aDRE group compared to the rPSA group. Furthermore, a majority of patients referred for aDRE had a normal posterior prostate appearance on MRI. An adjusted pathway for patients referred for aDRE with normal PSA, with DRE by a urologist prior to MRI, should be considered as it would likely reduce unnecessary investigations, treatment, and patient anxiety. These data suggest that this would not risk missing significant cancers.

Hypercalcemia-leukocytosis syndrome from non-schistosomiasis-associated squamous cell carcinoma of the urinary bladder: a case report and review of the literature.

BACKGROUND: Non-schistosomiasis-associated squamous cell carcinoma of the urinary bladder is less common in the Western world. Limited information on its possible paraneoplastic syndromes exists. Leukocytosis tends to commonly be regarded by clinicians as an indication of sepsis, rather than a feature of paraneoplasia, potential surrogate marker for recurrence, and prognostic marker. Accompanying hypercalcemia may be missed entirely. CASE PRESENTATION: A 66-year-old Caucasian man presented with visible painless hematuria and symptomatic hypercalcemia. Investigations revealed a squamous cell carcinoma of the urinary bladder with marked leukocytosis. Hypercalcemia and leukocytosis resolved following radical cystectomy, recurred with nodal recurrence and regressed with radiotherapeutic control. Subsequently, serum leukocyte and calcium assays were included in his follow-up protocol. His survival was 20 months by the time of the report. CONCLUSION: This report highlights hypercalcemia-leukocytosis syndrome as a paraneoplastic manifestation of non-schistosomiasis-associated squamous cell carcinoma to reemphasize the need for clinicians to assay for calcium in the presence of leukocytosis in such patients. Prompt identification and control of the paraneoplastic derangements, with treatment of the cancer recurrence it may connote, is advocated to provide a chance for better long-term outcomes in these patients.

Ureteric stent card register - a 5-year retrospective analysis.

INTRODUCTION: Ureteric stenting is a common urological procedure. Forgotten stents have a well-documented morbidity and mortality. Therefore, we asked the question, is a stent register an important factor in reducing the number of lost or overdue stents? PATIENTS AND METHODS: We conducted a retrospective review of 203 patients who had ureteric stents inserted in the operating theatre, for the 5-year period 1 December 1998 to 1 December 2003. We analysed all stent cards, patient notes and theatre logs; where no record of stent removal was found, we contacted the patient, their GP or their local hospital. RESULTS: A total of 191 patients were identified from the stent card register. An additional 12 patients were found from the theatre logs, but with no record in the stent card register. Of the 203 patients, 8 had bilateral stents. The most common indication for stenting was stone disease. Of the 203 patients, 11 had overdue stents and 51 had no record of the stents ever being removed. The 51 presumed 'forgotten' stents were traced, and it was found that 42 patients had had their stents removed by other hospitals, and 9 patients died with stents in situ, but before they were due for removal. CONCLUSIONS: Our current stent card tracking system is ineffective, because it was infrequently reviewed. However, despite overdue and 'forgotten' stents which were removed by other hospitals, no patients came to any real harm and we had no lost stents. Our stent register system did not appear to play any role in terms of preventing stent loss, and it seems likely that there are other more effective safeguards in place to prevent this from happening. However, if a stent register was required at all, a computerised system would be preferable. Alternatively, patients could share some of the responsibility of stent tracking with their clinicians.

Intraoperative flow measurements are helpful in the treatment of high-inflow steal syndrome on a predialysis patient with a brachiocephalic fistula: a case report.

Distal revascularization and interval ligation (DRIL) is currently one of the mainstay treatments for severe steal syndrome. However, when high inflow is the underlying cause, this technique does not fully address the problem. Here, we describe the use of intraoperative flow measurements using transit time ultrasound technology to help identify the cause of steal syndrome in a predialysis patient (no transonic surveillance) with a brachiocephalic fistula, who then was treated successfully by inflow reduction surgery using a bovine ureter graft. We believe that inflow reduction might be superior to DRIL in treating steal syndrome caused by high inflow and that transit time ultrasound might be helpful when transonic treatment is not possible.