Priapism in a Patient with Rectal Adenocarcinoma.

BACKGROUND: Priapism is a very rare complication of malignancy and is usually accompanied by locally advanced or widely metastatic disease. We describe a case of priapism arising in a 46-year-old male with localised rectal cancer that was responding to therapy. CASE PRESENTATION: This patient had just completed two weeks of neoadjuvant, long-course chemoradiation when he presented with persistent painful penile erection. Assessment and diagnosis were delayed for more than 60 h, and although a cause could not be determined from imaging, a near complete radiological response of the primary rectal cancer was seen. His symptoms were refractory to urologic intervention and were associated with extreme psychological distress. He re-presented shortly thereafter with extensively metastatic disease in the lungs, liver, pelvis, scrotum, and penis; additionally, multiple venous thromboses were identified, including in the dorsal penile veins. His priapism was not reversible and was associated with a considerable symptom burden for the remainder of his life. His malignancy did not respond to first-line palliative chemotherapy or radiation, and his clinical course was further complicated by obstructive nephropathy, ileus, and genital skin breakdown with a suspected infection. We initiated comfort measures, and he ultimately died in hospital less than five months after his initial presentation. CONCLUSION: Priapism in cancer is usually related to tumour infiltration of the penis and corporal bodies resulting in poor venous and lymphatic drainage. The management is palliative and can include chemotherapy, radiation, surgical shunting, and potentially penectomy; however, conservative penis-sparing therapy may be reasonable in patients with limited life expectancy.

Crowdfunding in urology: Canadian perspective.

INTRODUCTION: Crowdfunding is becoming an increasingly used resource for patients to cover costs related to medical care. These costs can be related directly to treatments or indirectly to loss of income or travel-related costs. Little is known as to the extent of which crowdfunding is used for urological disease here in Canada. This study offers a first look at the prevalence of crowdfunding for urological disease and the factors surrounding its use. METHODS: In January 2020, we queried the GoFundMe internal search engine for fundraising campaigns regarding urological ailments. Results were categorized according to the major organs of urological disease. RESULTS: Crowdfunding campaigns are very prevalent within several areas of urology. Prostate cancer and chronic kidney disease represent the most frequent reason for campaigns. Fundraising goals and actual funds raised for malignant disease were significantly more than for benign disease. Interestingly, there was a significant portion of crowdfunding campaigns to cover costs for non-conventional treatments and transplant tourism. CONCLUSION: Crowdfunding use to help cover direct and indirect costs of medical care is becoming increasingly apparent through several facets of medicine. This study shows that this statement holds true when looking at patients with urological disease in Canada. As urologists, we need to be aware of this trend, as it highlights the often-unforeseen financial burdens experienced by our patients.

Development and Acceptability Testing of a Patient Decision Aid for Urinary Diversion with Radical Cystectomy.

PURPOSE: The choice of urinary diversion at cystectomy is a life altering decision. Patient decision aids are clinical tools that promote shared decision making by providing information about management options and helping patients communicate their values. We sought to develop and evaluate a patient decision aid for individuals undergoing cystectomy with urinary diversion. MATERIALS AND METHODS: We used the IPDAS (International Patient Decision Aids Standards) to guide a systematic development process. A literature review was performed to determine urinary diversion options and the incidence of outcomes. We created a prototype using the Ottawa Decision Support Framework. A 10-question survey was used to assess patient decision aid acceptability among patients, allied health professionals and urologists. The primary outcome was acceptability of the patient decision aid. RESULTS: Ileal conduit and orthotopic neobladder were included as primary urinary diversion options because they had the most evidence and are most commonly performed. Continent cutaneous diversion was identified as an alternative option. Outcomes specific to ileal conduit were stomal stenosis and parastomal hernia. Outcomes specific to neobladder were daytime and nighttime urinary incontinence and urinary retention. Acceptability testing was completed by 8 urologists, 9 patients and 1 advanced practice nurse. Of the respondents 94% reported that the language was appropriate, 94% reported that the length was adequate and 83% reported that option presentation was balanced. The patient decision aid met all 6 IPDAS defining criteria, all 6 certification criteria and 21 of 23 quality criteria. CONCLUSIONS: We created a novel patient decision aid to improve the quality of decisions made by patients when deciding among urinary diversion options. Effectiveness testing will be performed prospectively.

Delivery of chemotherapy for testicular cancer in routine practice: A population-based study.

INTRODUCTION: Maintenance of chemotherapy dose intensity is a cornerstone of management in testicular germ cell tumors. We describe chemotherapy delivery and outcomes of patients in routine practice. METHODS: The Ontario Cancer Registry was linked to electronic records of treatment to identify patients diagnosed with testicular cancer treated with orchiectomy and chemotherapy from 2005 to 2010. We describe chemotherapy delivery and dose intensity. Overall survival was measured from the start of chemotherapy. RESULTS: During the study period, 552 new cases of testicular cancer were treated with orchiectomy and chemotherapy; drug/regimen details were available for 475 (86%) cases. The study population included 324 patients with nonseminoma and 151 with seminoma. The majority of patients were treated with bleomycin, etoposide, and cisplatin (BEP) (83%, 394/475) or etoposide and cisplatin (EP) (6%, 30/475); 89% (379/424) received 3 to 4 cycles of treatment. Thirty two percent of all BEP patients (125/394) had at least 1 dose omission of bleomycin; this rate increased to 51% of patients treated with BEP × 4. Eight percent (33/397) of evaluable BEP/EP patients had a dose reduction/omission of cisplatin and 21% (82/397) had a dose delay of >6 days. Among the BEP/EP cases, 44% (174/397) had reduced chemotherapy dose intensity. Five-year overall survival for all cases was 95%. CONCLUSIONS: Almost half of patients treated with BEP/EP chemotherapy in routine practice have some form of reduced chemotherapy delivery. Despite this, long-term survival in the general population is very high. Further studies are required to understand the extent to which dose delivery might influence outcomes.

Perioperative chemotherapy for urothelial carcinoma of the upper urinary tract: A systematic review and meta-analysis.

INTRODUCTION: Upper tract urothelial carcinomas are rare malignancies with differences in anatomy and biology requiring therapeutic strategies that differ from bladder cancer. The role of perioperative systemic therapy in this disease remains uncertain with limited data to support its use. A systematic review of the literature and meta-analysis was therefore undertaken to provide more information and guide clinical practice. METHODS: A literature search was performed using Embase and Medline databases with additional searches performed manually using terms associated with upper tract urothelial malignancies. Data was extracted from studies of patients that underwent nephrouretectomy for the management of upper tract urothelial carcinoma and received either neoadjuvant or adjuvant systemic therapy. Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were summated and analyzed using Cochrane Revman software Version 5.3. RESULTS: There were 13 comparative studies and no randomized studies identified for data extraction; 11 adjuvant and 2 neoadjuvant with 1170 patients receiving perioperative systemic therapy and 3472 controls that did not. Perioperative chemotherapy was associated with improved OS (HR 0.75, 95%CI 0.57-0.99), DFS (HR 0.54, 95%CI 0.32-0.92), and CSS (HR 0.69, 95%CI 0.42-1.15). CONCLUSIONS: The available data suggests that perioperative systemic therapy is associated with improved survival in patients with upper tract urothelial cancer.

Temporal trends in management and outcomes of testicular cancer: A population-based study.

BACKGROUND: Treatment guidelines for early-stage testicular cancer have increasingly recommended de-escalation of therapy with surveillance strategies. This study was designed to describe temporal trends in routine clinical practice and to determine whether de-escalation of therapy is associated with inferior survival in the general population. METHODS: The Ontario Cancer Registry was linked to electronic records of treatment to identify all patients diagnosed with testicular cancer treated with orchiectomy in Ontario during 2000-2010. Treatment after orchiectomy was classified as radiotherapy (RT), retroperitoneal lymph node dissection (RPLND), chemotherapy, or none. Surveillance was defined as no identified treatment within 90 days of orchiectomy. Overall survival (OS) and cancer-specific survival (CSS) were measured from the date of orchiectomy. RESULTS: The study population included 1564 and 1086 cases of seminomas and nonseminoma germ cell tumors (NSGCTs), respectively. Among patients with seminomas, there was a significant increase in the proportion of patients with no treatment within 90 days of orchiectomy (from 56% to 84%; P < .001); the use of RT decreased over time (from 38% to 8%; P < .001); and the use of chemotherapy remained stable (from 6% to 9%; P = .289). Practice patterns 90 days after orchiectomy remained stable over time among patients with NSGCTs: from 51% to 57% for no treatment (P = .435), from 43% to 43% for chemotherapy (P = .336), and from 9% to 3% for RPLND (P = .476). The OS rates for the entire cohort at 5 and 10 years were 97% and 96%, respectively; the CSS rates were 98% and 98%, respectively. There was no significant change in OS or CSS for patients with seminomas or NSGCTs during the study period. CONCLUSIONS: There has been substantial de-escalation in the treatment of testicular cancer in routine practice since 2000. Long-term survival in routine practice is excellent and has not decreased with the uptake of surveillance strategies. Cancer 2018;124:2724-2732. © 2018 American Cancer Society.

Partial cystectomy for urothelial carcinoma of the bladder: Practice patterns and outcomes in the general population.

INTRODUCTION: Partial cystectomy (PC) for urothelial carcinoma (UC) in selected patients may avoid the morbidity of radical cystectomy (RC). We describe use and outcomes of PC for UC in routine clinical practice. METHODS: All patients with urothelial carcinoma of the bladder (UCB) undergoing PC or RC in Ontario from 1994-2008 were identified using the Ontario Cancer Registry and linked electronic records. Pathology reports were reviewed. Variables associated with PC use were identified using logistic regression. Cox proportional hazards model identified factors affecting cancer-specific (CSS) and overall survival (OS). RESULTS: A total of 3320 patients underwent PC (n=181; 5%) or RC (n=3139; 95%) from 1994-2008. PC patients were older (36% 80+ years vs. 19%; p<0.001) and more likely to have organ-confined (

Prostate Cancer Registries: Current Status and Future Directions.

CONTEXT: Disease-specific registries that enroll a considerable number of patients play a major role in prostate cancer (PCa) research. OBJECTIVE: To evaluate available registries, describe their strengths and limitations, and discuss the potential future role of PCa registries in outcomes research. EVIDENCE ACQUISITION: We performed a literature review of the Medline, Embase, and Web of Science databases. The search strategy included the terms prostate cancer, outcomes, statistical approaches, population-based cohorts, registries of outcomes, and epidemiological studies, alone or in combination. We limited our search to studies published between January 2005 and January 2015. EVIDENCE SYNTHESIS: Several population-based and prospective disease-specific registries are currently available for prostate cancer. Studies performed using these data sources provide important information on incidence and mortality, disease characteristics at presentation, risk factors, trends in utilization of health care services, disparities in access to treatment, quality of care, long-term oncologic and health-related quality of life outcomes, and costs associated with management of the disease. Although data from these registries have some limitations, statistical methods are available that can address certain biases and increase the internal and external validity of such analyses. In the future, improvements in data quality, collection of tissue samples, and the availability of data feedback to health care providers will increase the relevance of studies built on population-based and disease-specific registries. CONCLUSIONS: The strengths and limitations of PCa registries should be carefully considered when planning studies using these databases. Although randomized controlled trials still provide the highest level of evidence, large registries play an important and growing role in advancing PCa research and care. PATIENT SUMMARY: Several population-based and prospective disease-specific registries for prostate cancer are currently available. Analyses of data from these registries yield information that is clinically relevant for the management of patients with prostate cancer.

The state and potential of social media in bladder cancer.

INTRODUCTION: Social media sites and services have become intimately woven into our interpersonal communications and have begun to stake a visible place in healthcare. Disease-specific Twitter hashtags, online patient groups and participation by patients, practitioners and advocacy groups are emblematic of this new paradigm. METHODS: A literature review and summary of resources and publications on bladder cancer and social media. RESULTS: A majority of Western patients have access to and use the Internet for health information. Urologists and oncologists have used bladder-cancer-specific messaging at international meetings infrequently as compared to prostate and other non-urologic cancers. An active community does participate in online discussion, with differences between medical practitioners and patients/advocates. Advice is given with the aim of unifying this discussion.

Outcomes of squamous histology in bladder cancer: a population-based study.

OBJECTIVES: Squamous cell carcinoma (SCC) of the bladder is an uncommon form of bladder cancer. Using a large population-based sample we sought to describe the outcomes of patients with squamous histology and to define the factors that influence prognosis in these patients. METHODS: All incident cases of bladder cancer in Ontario undergoing cystectomy from 1994 to 2008 were identified. Electronic treatment records and detailed pathologic information were linked to the study data set. Patients were divided into 3 cohorts: pure SCC, urothelial carcinoma (UC) with squamous differentiation (UCSD), and pure UC. Cox modeling was performed to evaluate factors associated with overall survival (OS) and cancer-specific survival (CSS). RESULTS: There were identified 178, 325, and 2,884 cases of SCC, UCSD, and UC, respectively. The unadjusted 5-year OS for these groups were 33%, 28%, and 34%, respectively. Patients had higher rates of T3/4 disease with SCC (72%) and UCSD (73%) than those with UC (61%, P<0.001). There was no difference in node positivity among groups (20%, 27%, and 25%, P = 0.519). After adjusting for covariates, SCC did not portend a worse survival, at 5 years. However, SCC did result in a more rapid disease trajectory, with survival curves of SCC and UC crossing at the 5-year mark. Adjusted CSS/OS of UCSD was also not significantly different from UC. Among those patients with SCC, factors associated with CSS included age>70 (hazard ratio [HR] = 1.96, 95% CI: 1.16-3.30), T category≥3 (HR = 2.09, 95% CI: 1.24-3.50), N positive disease (HR = 2.59, 95% CI: 1.55-4.32), lymphovascular invasion (HR = 1.98, 95% CI: 1.13-3.47), and positive surgical margins (HR = 2.95, 95% CI: 1.47-5.93). CONCLUSIONS: After adjusting for patient and disease characteristics, we have found that SCC leads to a more rapid disease course with survival that is equivalent to UC by 5 years.

Computer-Aided Prostate Cancer Detection Using Ultrasound RF Time Series: In Vivo Feasibility Study.

UNLABELLED: This paper presents the results of a computer-aided intervention solution to demonstrate the application of RF time series for characterization of prostate cancer, in vivo. METHODS: We pre-process RF time series features extracted from 14 patients using hierarchical clustering to remove possible outliers. Then, we demonstrate that the mean central frequency and wavelet features extracted from a group of patients can be used to build a nonlinear classifier which can be applied successfully to differentiate between cancerous and normal tissue regions of an unseen patient. RESULTS: In a cross-validation strategy, we show an average area under receiver operating characteristic curve (AUC) of 0.93 and classification accuracy of 80%. To validate our results, we present a detailed ultrasound to histology registration framework. CONCLUSION: Ultrasound RF time series results in differentiation of cancerous and normal tissue with high AUC.