Cardiovascular risks of androgen receptor targeted agents in prostate cancer: a systematic review and meta-analysis.

INTRODUCTION: Androgen receptor targeted agents (ARTA) have increasingly been incorporated into treatment regimens for various stages of prostate cancer. Patients are living longer with prostate cancer, and thus have a higher cumulative exposure to the treatment and its accompanying side effects, especially those of cardiovascular disease. We aim to assess the differences in the incidence of cardiac-related adverse events after treatment of prostate cancer with ARTA versus placebo. METHODS: Three databases were thoroughly searched for relevant articles. The PICOS model was used to frame our clinical question, with which 2 independent authors went through several rounds of screening to select the final included studies. Meta-analysis was done using the Cochran-Mantel-Haenszel Method. Quality assessment was carried out with the Cochrane Risk of Bias tool RoB 2. RESULTS: The use of ARTA in prostate cancer increases the incidence of cardiac-related adverse events (RR: 1.56, 95% CI: 1.29-1.90, p < 0.00001), such as hypertension (RR: 1.69, 95% CI: 1.46-1.97, p < 0.00001), ischaemic heart disease (RR: 1.84, 95% CI: 1.36-2.50, p < 0.0001), and arrhythmia (RR: 1.38, 95% CI: 1.11-1.71, p = 0.004), although this did not manifest in an increased incidence of cardiac arrests/deaths (RR: 1.28, 95% CI: 0.87-1.88, p = 0.21). DISCUSSION: ARTA increases the risk of cardiac-related adverse events, hypertension, ischaemic heart disease and arrhythmia. Armed with this knowledge, we will be better poised to manage cardiac risks accordingly and involve a cardiologist as required when starting patients on ARTA.

Convective Water Vapour Energy Ablation (Rezum®) versus Prostatic Urethral Lift (Urolift®); A 2-Year Prospective Study.

Introduction To compare the clinical outcomes and complication rates of Convective Water Vapour Energy Ablation (Rezum®) and Prostatic Urethral Lift (Urolift®). To identify predictive factors for treatment failures in both treatments. Materials & Methods Prospective clinico-epidemiological data of patients who underwent Urolift® or Rezum® in a single institution for Benign Prostatic Hyperplasia (BPH) was collected. The choice of intervention depended on the preference of the patients after patient-centric discussions. Results From October 2019 to October 2022, 86 patients underwent Rezum® and 62 patients underwent Urolift®. Rezum® involved a longer indwelling catheter duration (12.38±5.548 versus 1.39±3.010 days, p<0.001) compared to Urolift®. Rezum® was associated with more complications compared to Urolift® (36 (41.9%) versus 10 (16.1%) cases, p<0.001). Rezum® had more cases of hematuria (17 (19.8%) versus 4 (6.5%) cases (p=0.022)) and urinary tract infections (27 (31.4%) versus 3 (4.8%) cases, p<0.001)), compared to Urolift®. There were no significant differences in Clavien-Dindo Grade 3-5 complications between the interventions. Urolift® was associated with higher re-operation rates (5 (8.1%) versus 0 (0%) cases, p=0.010) compared Rezum®. Rezum® had higher anti-cholinergic usage rates compared to Urolift® post-operation (22 (25.6%) versus 8 (12.9%) cases, p=0.024). Both interventions showed improvement in International Prostate Symptom Score (IPSS), Quality of Life score, and peak velocity flow over the 2 years with no significant difference between the two. Based on receiver operating characteristic curve, pre-operation IPSS ≥ 16 had 95.7% sensitivity and 38.4% specificity to predict the probability of treatment failures after the interventions. Conclusions There was no difference in clinical outcomes of patients who underwent Rezum® and Urolift®. However, patients who had undergone Rezum® faced more minor complications and more required anti-cholinergic medications. Lastly, physicians should note that patients with IPSS≥16 would unlikely benefit from either intervention.

Implementation of a Ureteric Colic Telemedicine Service: A Mixed Methods Quality Improvement Study.

OBJECTIVE: To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments. METHODS: A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians. RESULTS: Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service. CONCLUSION: The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic.

Tips and Tricks to Improve Ergonomics, Efficacy, Versatility, and Overcome Limitations of Micro Percutaneous Nephrolithotomy.

Percutaneous Nephrolithotomy (PCNL) has evolved over the decades from Standard to Mini to Ultramini PCNL to Micro-perc, with miniaturisation being the dominant theme and supine approach gaining momentum world over. Aim: In literature, miniaturised PCNL with microperc needle access system has raised concerns of intrarenal pressure and has some limitations with its success for larger stones. Our tips and tricks explain how to overcome these pitfalls by utilising the full construct of the needle system to its maximum potential. These will in turn help make the procedure versatile, precise, ergonomical, and enhance a surgeon's experience with improved outcomes for patients especially in large renal stones. Materials and Methods: We describe the limitations of microperc needle access as stated in literature and proposals by the co-authors using microperc for miniaturised access on how to overcome the same. Results: A simplified table describing the limitations and tips and tricks on overcoming these is provided for quick reference. Conclusion: As Technological advancements and techniques for miniaturised access in urolithiasis improve, we believe our suggestions will help surgeons overcome the quoted limitations of microperc needle access for miniaturised PCNL, making this a versatile, safe and efficacious technique even in large and complex stones. A multi centre trial will be the best way to validate the suggestions proposed in this article.