Seminal Papers in Urology: Darolutamide and survival in metastatic, hormone-sensitive prostate cancer.

The ARASENS trial recruited 1306 men with metastatic hormone sensitive prostate cancer. It investigated the effect of androgen deprivation therapy (ADT) and systemic therapy docetaxel in combination with a third novel drug - daralutamide, compared with placebo on overall survival. Triple therapy with ADT, docetaxel and darolutamide resulted in improved overall survival rates as compared with ADT, docetaxel and placebo (HR 0.68; 95% CI, 0.57-0.80; p < 0.001). The side effect profile for both treatments was similar. This randomised, double blinded, placebo controlled study, was assessed to have a low risk of bias using the Cochrane Risk of Bias 2 tool.

Systematic Review of Local Anaesthetic Systemic Toxicity in Urology.

OBJECTIVE: To systematically evaluate cases of local anaesthetic systemic toxicity (LAST) in adult urological patients. METHODS: A search of the Cochrane, Embase, and Medline databases as well as grey literature from 1 January 1974 to 1 February 2023 was performed using reported methods. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible studies were published in English, described LAST secondary to local anaesthetic administration by urological medical staff to an adult patient, and reported >1 symptom of LAST. RESULTS: One hundred fifty-seven publications were screened, and six eligible studies (all case reports) were identified, representing six cases of LAST in adult urological patients. Patients were aged 29-54 years and one was female. Cases occurred secondary to penile dorsal nerve block (two cases), scrotal self-injection (two), circumcision (one) or trans-vaginal tape insertion (one). Causative drugs were lidocaine (three patients; median dose 600mg) and bupivacaine (three; 200mg). While one patient was found deceased at home and received no treatment, five experienced LAST as inpatients and were discharged with no deficit. Three patients (50%) experienced a state of reduced consciousness or seizures, one experienced psychosis and one had asymptomatic tachyarrhythmia. Management consisted of supportive management (five patients), intravenous lipid emulsion (three) or intravenous thiopental and diazepam (one). Recommended tools suggested that two of these studies were at moderate or high risk of bias. CONCLUSION: LAST is seen only rarely in adult urology. Most iatrogenic cases occur due to penile dorsal nerve block and most patients have no long-term sequelae. Urologists should be familiar with its presentation and management, and minimise risk by adhering to local anaesthetic maximum safe dose ranges.