Teaching medical students digital rectal examination: a randomized study of simulated model vs rectal examination volunteers.

OBJECTIVES: To determine if using a digital rectal examination (DRE) human volunteer improves medical students' confidence in performing DRE in comparison to using a simulated model alone. PARTICIPANTS AND METHODS: Medical students underwent randomization into one of two groups: a control group who underwent standard teaching and an intervention group who underwent standard teaching plus further tuition involving a DRE volunteer. Standard teaching involved a 30-min lecture and a practice DRE on a simulation model. The intervention group additionally observed a tutor demonstrating DRE on a volunteer, then conducted a DRE themselves under supervision. Before and after teaching, both groups completed a survey comprised of three questions. The primary endpoint was confidence in performing a DRE, which was assessed according to the sum of the scores from the three questions. RESULTS: In total, 48 students were randomized, 22 to the control group and 26 to the intervention group. The groups were well matched prior to teaching DRE (P = 0.76) After the DRE tutorial, students in the intervention group were more confident in knowing the indications for DRE (P = 0.001), more confident in their technique for performing DRE (P < 0.001) and more confident in their ability to assess findings accurately at DRE (P < 0.001). The primary outcome measure, overall confidence (sum of the scores from all three questions) in performing DRE, was significantly better in the intervention group (score 10/15 vs 14/15; P < 0.001). CONCLUSION: This study showed that teaching DRE with the assistance of volunteer patients improves inexperienced students' confidence in performing DRE, and the incorporation of such training should be considered in the DRE education programme.

Single use versus reusable digital flexible ureteroscopes: A prospective comparative study.

OBJECTIVES: To compare the performance and surgical outcomes of two different single-use digital flexible ureteroscopes with a reusable video flexible ureteroscope. METHODS: Patients undergoing retrograde flexible ureteroscopy at Nepean Hospital, Sydney, Australia, were included in this study. Three different flexible ureteroscopes were used in this study: (i) single-use digital LithoVue (Boston Scientific, Marlborough, MA, USA); (ii) single-use digital PU3022A (Pusen, Zhuhai, China); and (iii) reusable digital URF-V2 (Olympus, Tokyo, Japan). Visibility and maneuverability was rated on a 5-point Likert scale by the operating surgeon. Operative outcomes and complications were collected and analyzed. RESULTS: A total of 150 patients were included in the present study. Of these, 141 patients had ureteroscopy for stone treatment, four for endoscopic combined intrarenal surgery and five for diagnostic/tumor treatment. There were 55 patients in the LithoVue group, 31 in the PU3022A group and 64 patients in the Olympus URF-V2 group. The URF-V2 group had higher visibility scores than both the single-use scopes and higher maneuverability scores when compared with the PU3022A. The LithoVue had higher visibility and maneuverability scores when compared with the PU3022A. There were no differences in operative time, rates of relook flexible ureteroscopes, scope failure or complication rates observed. CONCLUSIONS: Single-use digital flexible ureteroscopes have visibility and maneuverability profiles approaching that of a reusable digital flexible ureteroscope. Single-use flexible ureteroscopes achieve similar clinical outcomes to the more expensive reusable versions.

68Ga-PSMA PET/CT versus CT and bone scan for investigation of PSA failure post radical prostatectomy.

OBJECTIVE: To evaluate the use of Gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA PET/CT), compared with conventional CT abdomen/pelvis (CTAP) and whole body single photon emission CT bone scan (BS), for detection of local or distant metastasis following biochemical failure/recurrence in post-prostatectomy patients. METHODS: We conducted a review of our prospectively maintained, institutional database to identify 384 patients with post-prostatectomy biochemical failure/recurrence who underwent PSMA PET/CT, CTAP and BS from February 2015 to August 2017 in Nepean Hospital, tertiary referral centre. The results of the three imaging modalities were analysed for their ability to detect local recurrence and distant metastases. PSMA PET/CT and CTAP imaging were separately performed on the same day and the BS was performed within several days (mostly in 24 h). Difference in detection rates was determined between the modalities and the Chi square test was used to determine significance. RESULTS: A total of 384 patients were identified with a median prostate-specific antigen (PSA) of 0.465 ng/mL (interquartile range =0.19-2.00 ng/mL). Overall, PSMA PET/CT was positive for 245 (63.8%) patients whereas CTAP and BS were positive in 174 patients (45.3%). A total of 98 patients (25.5%) had local or distant metastasis detected on PSMA only, while 20 patients (5.2%) had recurrences detected on CTAP but not on PSMA PET/CT. CONCLUSION: The use of PSMA PET/CT has a higher detection rate of predicted local or distant metastasis compared to CTAP and BS in the staging of patients with biochemical recurrences after radical prostatectomy.

A Rare Case of Ureteral IgG4 Disease Masquerading as Urothelial Carcinoma.

The present paper described a rare case of ureteral IgG4-related disease (IgG4-RD) that mimicked urothelial carcinoma. An otherwise healthy patient presented with computed tomography, ureteroscopic, and biopsy findings that were suspicious of urothelial carcinoma. The patient received a right nephroureterectomy. Histopathology showed ureteral IgG4-RD, without evidence of urothelial carcinoma. Accurate diagnosis of this rare entity should be based on clinical, biochemical, and histopathological findings.

Cytoreductive nephrectomy for metastatic renal cell carcinoma: inequities in access exist despite improved survival.

The use of cytoreductive nephrectomy (CRN) in the targeted therapy era is still debated. We aimed to determine factors associated with reduced use of CRN and determine the effect of CRN on overall survival in patients with metastatic renal cell carcinoma (RCC). All advanced RCC diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment and death were electronically linked. Follow-up was to the end of 2011. Multivariable logistic regression analysis was used to determine factors associated with the receipt of CRN. Cox proportional hazards model was used to determine factors associated with survival. A total of 1062 patients were identified with metastatic RCC of whom 289 (27%) received CRN. There was no difference in the use of CRN over the time period of the study. Females (OR 0.68 (95% CI: 0.48-0.96)), unmarried individuals (OR 0.68 (95% CI: 0.48-0.96)), treatment in a nonteaching hospital (OR 0.26 (95% CI: 0.18-0.36)) and individuals without private insurance (OR 0.29 (95% CI: 0.20-0.41)) all had reduced likelihood of receiving CRN. On multivariable analysis, not receiving CRN resulted in a 90% increase in death (HR 1.90 (95% CI: 1.61-2.25)). In addition, increasing age (P < 0.001), increasing Charlson comorbidity status (P = 0.002) and female gender also had a significant independent association with death. Despite a strong association with improved survival, individuals who are elderly, female, have treatment in a nonteaching facility or have no private insurance have a reduced likelihood of receiving CRN.

Testicular infarction and rupture: an uncommon complication of epididymo-orchitis.

Epididymo-orchitis is a common diagnosis in men presenting with unilateral testicular pain. It can be of an infectious or non-infectious aetiology. Clinical examination and laboratory investigations do not reliably differentiate testicular infarction secondary to epididymo-orchitis from uncomplicated epididymo-orchitis. Definitive diagnosis is usually made by ultrasound. Misdiagnosis and under-treatment can lead to poor outcome, such as infarction and loss of the affected testis. We present an uncommon case of epididymo-orchitis resulting in testicular infarction and rupture despite normal initial investigations.