Time for a mandatory urology rotation? Adequacy of urological exposure during medical school - a survey of graduates of the University of the West Indies, Trinidad and Tobago.

INTRODUCTION: To objectively assess the self-reported adequacy and utility of exposure of our students to urology during their training. MATERIALS AND METHODS: A questionnaire was sent to the University of the West Indies graduating class of 2018, now functioning as medical interns. A questionnaire was designed to collect information regarding respondent demographics, perceptions of their urology exposure during their medical school training as well as their attitudes towards the specialty. The survey was also designed to capture respondents' comfort levels with commonly encountered urological scenarios and investigations. The survey was distributed in February 2019 using the online survey tool, Survey Monkey. RESULTS: A total of 196 surveys were distributed, of which 107 responses were returned. Clinic exposure was the most common form of interaction with the specialty during training. Their exposure to common urological procedures was low with only 9.3% and 4.7% having seen a circumcision or prostate biopsy respectively by graduation; 21.7% and 47.7% indicated that they were uncomfortable to review a KUB X-ray and CT respectively to identify a stone; 96.2% considered urology to be an important clinical sub-specialty but 42.4% indicated that their exposure to urology did not prepare them to manage urological conditions that they have encountered since graduation; 87.8% of respondents supported the idea of a urology rotation. CONCLUSION: The exposure of medical students to urology during their medical training is poor. There remains much room for improvement in exposing our medical students to urology during their training. A dedicated urology rotation should be strongly considered. This study has applications not just within the Caribbean, but further afield.

High Self-Reported Prevalence of Kidney Stones in Trinidad and Tobago: Results of a Cross-Sectional Online Survey.

Introduction No data exist on the prevalence of kidney stone disease in Trinidad and Tobago. Local clinicians have noted that the disease is very common, and this study represents the first attempt to investigate the prevalence of urolithiasis in these islands. Objectives The objective is to estimate the prevalence of kidney stone disease in Trinidad and Tobago and to investigate the epidemiology of the disease. Methods An online survey using the online tool Survey Monkey was distributed among members of the public via instant messaging and social media. The survey captured data relating to the stone status and demographics of respondents. Results 1225 patients completed the survey of whom 46.5% were males and 53.5% were females. Respondents were equally distributed throughout the country. 16.74% of those surveyed indicated that they were currently affected by stones confirmed by imaging. Kidney stones were more common among Trinidadians of East Indian ancestry (20.6% vs 10.6%). Positive correlations were established between kidney stones and the presence of hypertension, diabetes, and gout. Persons with kidney stones were more likely to have a family member with the disease - 45.6% vs 31.4% among those without kidney stones. Conclusion This study demonstrates a high self-reported prevalence of kidney stones in Trinidad and Tobago.

Could Use of a Flexible and Navigable Suction Ureteral Access Sheath Be a Potential Game-changer in Retrograde Intrarenal Surgery? Outcomes at 30 Days from a Large, Prospective, Multicenter, Real-world Study by the European Association of Urology Urolithiasis Section.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the stone-free status (SFS) rate and complications after flexible ureteroscopy (fURS) for treatment of renal stones using a flexible and navigable suction (FANS) ureteral access sheath. METHODS: Data for adults undergoing fURS in 25 centers worldwide were prospectively collected (August 2023 to January 2024). Exclusion criteria were abnormal renal anatomy and ureteral stones. All patients had computed tomography scans before and within 30 d after fURS with a FANS ureteral access sheath. SFS was defined as follows: grade A, zero fragments; grade B, a single fragment ≤2 mm; grade C, a single fragment 2.1-4 mm; and grade D, single/multiple fragments >4 mm. Data for continuous variables are presented as the median and interquartile range (IQR). Multivariable logistic regression was performed to evaluate predictors of grade A SFS. KEY FINDINGS AND LIMITATIONS: The study enrolled 394 patients (59.1% male) with a median age of 49 yr (IQR 36-61). The median stone volume was 1260 mm3 (IQR 706-1800). Thulium fiber laser (TFL) was used in 45.9% of cases and holmium laser in the rest. The median lasing time was 18 min (IQR 11-28) and the median operative time was 49 min (IQR 37-70). One patient required a blood transfusion and 3.3% of patients had low-grade fever. No patient developed sepsis. Low-grade ureteral injury occurred in eight patients (2%). The grade A SFS rate was 57.4% and the grade A + B SFS rate was 97.2%, while 2.8% of patients had grade C or D SFS. Eleven patients underwent repeat fURS. Multivariable analysis revealed that a stone volume of 1501-3000 mm3 (odds ratio 0.50) and of >3000 mm3 (odds ratio 0.29) were significantly associated with lower probability of grade A SFS, while TFL use was associated with higher SFS probability (odds ratio 1.83). Limitations include the lack of a comparative group. CONCLUSIONS AND CLINICAL IMPLICATIONS: fURS using a FANS ureteral access sheath resulted in a high SFS rate with negligible serious adverse event and reintervention rates. PATIENT SUMMARY: We looked at 30-day results for patients undergoing telescopic laser treatment for kidney stones using a special type of vacuum-assisted sheath to remove stone fragments. We found a high stone-free rate with minimal complications.

Clinicopathological Profile of Renal Cancer in a Caribbean Hospital: Analysis of a Surgical Case Series.

Objective To document the demographic and pathological profile of renal cancer at San Fernando General Hospital (SFGH), Trinidad and Tobago over a five-year period (2015-2019). Methods This is a retrospective study that was conducted on all patients who had a histological diagnosis of renal cancer with surgical treatment from 2015-2019 at SFGH. Data were collected on patient demographics, clinical presentation, and pathological characteristics such as cancer size, location, and grade. Data were tabulated on Microsoft Excel and results were summarized using descriptive statistics. Results Over a 5-year period, there were 42 patients diagnosed with kidney cancer who had surgical intervention. The age ranged from 18 to 81 years with a mean age of 61 years and 67% of patients were over the age of 60. Males consisted of 57% of all patients. Most patients presented with pain, hematuria, or both. The majority (93%) of the patients had radical surgical treatment with equal distribution of right and left tumors. Clear cell carcinoma is the most common renal cell carcinoma (RCC), accounting for 80.5% followed by papillary with 16.7%. The majority of renal cell tumors were Fuhrman grade 2 with negative surgical margins and no lymphovascular invasion. The average maximum tumor dimension was 4.2 cm. Conclusions This study shows that in our hospital renal cancer affects primarily older patients, mostly men with the common presentation of pain and hematuria. The tumors are commonly clear cell RCC, grade 2 with negative margins, no lymphovascular invasion, and an average maximum dimension of 4.2 cm.

Spontaneous Massive Intrarenal Hemorrhage in a Patient With De Novo Ureteropelvic Junction Obstruction.

This case represents an even rarer presentation of ureteropelvic junction obstruction (UPJO), that of a spontaneous life-threatening hemorrhage into the renal pelvis of a patient with previously unknown UPJO. Unique to this patient was the emergent nature of the presentation, requiring life-saving surgery. A review of the literature follows a discussion of the case.

Home grown: the development and structure of urological training in the Caribbean.

Training in general surgery at the University of the West Indies commenced in Jamaica in 1972 and urology training followed just over a decade later. Since then, the 'Doctor of Medicine' diploma offered by the university has also expanded to include the Trinidadian campus. Most urologists in the English-speaking Caribbean are, in fact, graduates of this programme. Residents follow a two-part training plan and two years of core surgical training are followed by four years of urology training. Despite the tremendous regional impact of this training programme, there is a lack of awareness of its existence among the wider urology community. This article reviews the history, development and structure of urology training in the English-speaking Caribbean.

Minimally invasive urology - Pearls, pitfalls and experience in the Caribbean.

The Caribbean is made up of several independent nations and the availability of urology and more specifically endourology services varies widely between them. In this article we explore the history and current state of endourology in the English speaking Caribbean as well as the challenges faced within the region many of which are shared by the different territories.

Nurse-led renal cancer follow-up is safe and associated with high patient satisfaction-an audit from the East of England.

BACKGROUND: With more people diagnosed and dying from renal cancers in England than ever before, treatment and follow-up post-surgery is of paramount importance. We have instituted a nurse-led follow-up service for renal cancers as a way to improve efficiency and make better use of clinic time. This is our first attempt to audit our service. OBJECTIVES: One of the main objectives of this project was to measure compliance of a nurse-led renal surveillance clinic against an established institutional follow-up protocol which was based on current European Association of Urology guidelines. We also aimed to assess patient satisfaction with nurse-led care. PATIENTS AND METHODS: A total of 89 patients with low/intermediate-risk kidney cancers who were on the nurse-led renal surveillance database following nephrectomy or partial nephrectomy were placed on a database. This was then audited for adherence to the clinic protocol. These same patients were subsequently sent patient satisfaction questionnaires. RESULTS: The audit revealed high levels of compliance against the renal clinic protocol as well as positive feedback from the patient satisfaction questionnaire. Ninety-five percent said they felt either at ease or very at ease speaking to the nurse specialist. No one was dissatisfied with their consultations with 86% being very satisfied and 14% fairly satisfied. This was reinforced further by 100% of patients feeling that they could discuss all aspects of their condition with the Uro-oncology Clinical Nurse Specialist (UOCNS). Ninety-seven percent felt that they had adequate time with the nurse. CONCLUSION: Nurse-led follow-up, in our setting, was noted to be safe and effective and was associated with high levels of patient satisfaction. This study adds to the growing body of work on the efficacy of nurse-led care.

Prostate-specific antigen-based screening in Afro-Caribbean men: a survey of members of the Caribbean Urological Association.

OBJECTIVES: To examine the attitudes, beliefs and practices of Caribbean urologists regarding prostate-specific antigen (PSA)-based screening in the Caribbean region particularly as it relates to Afro-Caribbean men. DESIGN: An Internet-based descriptive cross-sectional study using a standardised questionnaire designed to capture information on respondents' attitudes, beliefs and practices towards PSA-based screening was conducted using the online survey tool Survey Monkey among known urologists in the Caribbean, based on the complete mailing list of the membership of the Caribbean Urological Association. RESULTS: Thirty of the total population of 40 urologists (75%) from nine countries in the Caribbean completed the survey. Twelve (40%) were from Jamaica and eight (26.7%) were from Trinidad. Two-thirds (n = 20) of the urologists believed that PSA-based screening has positively impacted survival in their population and 76.7% (n = 23) supported the PSA-based screening in the Afro-Caribbean male. Seventy-eight percent believed that guidelines from other countries were not applicable to the Caribbean and 63% believed that a regional body should publish its own guidelines. Most supported yearly screening with the PSA and digital rectal examination beginning at age 40 for Afro-Caribbean men but opinion varied regarding PSA-based screening of Indo-Caribbean men. Respondents were unanimous in their belief that there should be an upper age limit for screening, 75 years old being the most commonly reported. CONCLUSION: Most Caribbean urologists favour PSA-based screening in Afro-Caribbean men and recommend that Caribbean-specific guidelines need to be drafted.

The current state of prostate cancer treatment in Trinidad and Tobago.

Prostate cancer mortality in the Caribbean region is among the highest in the world and prostate cancer is the most common cancer in Trinidad and Tobago. There is a two-tiered healthcare system in Trinidad and Tobago, and prostate cancer related issues account for a significant percentage of urologists' workload. Delivery of care is sometimes constrained by limited financial resources. Prostate-specific antigen testing is widely available but there is no national guideline. Treatment options available include active surveillance, radical prostatectomy, external beam radiotherapy and brachytherapy. Patients have access to androgen deprivation, chemotherapy and palliative care for the management of advanced disease. Generally, the infrastructure for treatment in Trinidad and Tobago is satisfactory but would benefit from further investments in technology and human resources.

Nurse-led active surveillance for prostate cancer is safe, effective and associated with high rates of patient satisfaction-results of an audit in the East of England.

INTRODUCTION: Active surveillance (AS) is an option in the management of men with low-stage, low-risk prostate cancer. These patients, who often require prolonged follow-up, can put a strain on outpatient resources. Nurses are ideally placed to develop advanced roles to help meet this increased demand-a model we have utilised since 2014. We set about to comprehensively evaluate our nurse-led AS (NLAS) programme. PATIENTS AND METHODS: An audit of patient notes was carried out to assess compliance with trust and national guidelines. A questionnaire was designed to capture patients' experiences of NLAS. This was piloted and then distributed to all patients in our NLAS programme. A second questionnaire was designed to assess the views of stakeholders within the department. RESULTS: Compliance with various aspects of local guidelines ranged from 88.8% to 100%. 143 patients are currently in the programme with a mean duration of AS of 37.03 months. 104 questionnaires were returned. Most of the patients were aware of the role of the nurse prior to their visit, and all were happy to meet with a nurse. All of the patients indicated their confidence in the nurse monitoring their prostate-specific antigen. Among those requiring further investigations, 85.3% were happy with the information they received prior to their tests. Overall, 96.2% were either very satisfied or satisfied with NLAS. All stakeholders held positive views about NLAS. CONCLUSIONS: NLAS is safe and effective. Patients and stakeholders alike held positive views of the programme.

A Clinicopathological Profile of Prostate Cancer in Trinidad and Tobago.

Aim. To conduct a clinicopathological review of all prostate biopsies performed in a tertiary referral centre in Trinidad and Tobago over a period of 30 months. Methods. The records of all patients who had prostate biopsies from January 2012 to July 2014 were reviewed. Clinical and pathologic data were compiled and subsequently analysed using SPSS version 20. Results. From January 2012 to July 2014, 617 transrectal ultrasound guided prostate biopsies were performed. Pathological data were found for 546 patients of whom 283 (51.8%) were confirmed carcinoma of the prostate. Moderately differentiated tumors (Gleason 7) were the most common group. Using the D'Amico risk classification, most cases were found to be high risk (63.1%). Afro-Trinidadians comprised 72.1% of the patients with prostate cancer. Afro-Trinidadians were also more likely to have high risk and high grade disease as well as high PSA values. Conclusion. This study demonstrates that over half of our biopsies are eventually positive for cancer and most cases were high risk. Afro-Trinidadians comprised a disproportionate number of those diagnosed with prostate cancer and had a greater risk of high risk disease.