Non-technical skills for urological surgeons (NoTSUS): development and evaluation of curriculum and assessment scale.

OBJECTIVE: In the last decade non-technical skills (NTS) have emerged as a vital area for improvement within surgery. This study aims to develop and evaluate a Non-technical Skills for Urological Surgeons (NoTSUS) training curriculum and assessment scale. METHODS: This international, longitudinal and observational study began with a 3-round Delphi methodology to refine curriculum contents and rating scale. Sessions with up to four participants were delivered where each candidate undertook an independent scenario within the validated full immersion simulation environment. Candidates were assessed using both the NoTSS (Non-technical Skills for Surgeons) and NoTSUS rating scales by NTS-trained and non-trained experts. A post-training evaluation survey was distributed. RESULTS: 62 participants comprising trainees (n = 43) and specialists (n = 19) undertook the NoTSUS course. The NoTSS and NoTSUS scales correlated well, with a mean difference of 3.3 in the overall total (p = 0.10, r = 0.53). However, there was significant differences in scores between the NoTSS-trained and non-trained raters (n = 28, p = 0.03). A one-way ANOVA test revealed significant improvement throughout the four simulation scenarios in each session (p = 0.02). The NoTSUS curriculum received positive feedback from participants and demonstrated educational value and acceptability. CONCLUSIONS: The NoTSUS curriculum has demonstrated high educational value for NTS training aimed at urologists, with marked improvement throughout sessions. Correlation of NoTSUS and NoTSS scales proves its suitability for evaluating NTS in future training. Demonstration of inter-rater reliability indicates that the scale is reliable for use in assessment by expert faculty members. Furthermore, qualitative feedback from participants suggests gain of transferrable skills over the course.

Fertility managment in testicular cancer: the need to establish a standardized and evidence-based patient-centric pathway.

OBJECTIVES: The aim of the present paper was to determine the impact of testicular cancer (TC) and its treatments on fertility and to review the current management options for the infertile patient with TC, both before diagnosis and after treatment, with the aim of providing practical recommendations to update contemporary guidelines and standardize clinical practice. PATIENTS AND METHODS: Searches were conducted for relevant articles on Pubmed and Google Scholar between 2000 and 2017, with additional articles sourced from reference lists of included publications. RESULTS: At time of diagnosis, 6-24% of patients with TC were reported to be azoospermic and 50% oligozoospermic. Without conducting semen analysis at diagnosis, these patients cannot be identified and may be at further risk of subfertility. Gonadotoxic therapies cause an overall decrease in male fertility by 30% and there is currently no method to predict which patients will become azoospermic after treatment. Patients with larger, more invasive tumours, however, are at greater risk of infertility from local tumour effects, and are also more likely to undergo several different type of therapy, which has further detrimental effects on conception rates. Most treatment-induced infertility recovers 2 years post-treatment, but paternity can be delayed during a couple's peak reproductive years. Semen cryopreservation remains the procedure of choice in preserving fertility, but the service is underused, with only 24% of patients banking sperm. Microdissection testicular sperm extraction (microTESE) at the time of orchidectomy (onco-microTESE) is a successful infertility treatment option for those found to be azoospermic or severely oligozoospermic at diagnosis, while microTESE may still retrieve sperm in azoospermic patients after chemotherapy. CONCLUSION: The underutilisation of semen analysis and sperm cryopreservation results in the failure to identify the azoospermic or severely oligozoospermic patient at diagnosis who may benefit from fertility-preserving procedures, for example, onco-microTESE at the time of orchidectomy. Fertility preservation and counselling needs to be broached earlier in the TC treatment pathway and made a greater priority. Given the advances in treatment, more patients with TC are surviving and looking to return to a normal life. Preserving their future fertility plays an important role in achieving this.

Male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition: a meta-analysis.

We aimed to assess male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition in heterosexual and homosexual men using all available data. A systematic literature review was conducted searching for studies that assessed male circumcision as a method to prevent HIV acquisition in homosexual and/or heterosexual men. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov were searched in March 2017. A random effects model was used to calculate a pooled risk ratio (RR) and its associated 95% confidence interval (CI). In total, 49 studies were included in this meta-analysis. The overall pooled RR for both homosexual and heterosexual men was 0.58 (95% CI 0.48-0.70), suggesting that circumcision was associated with a reduction in HIV risk. Circumcision was found to be protective for both homosexual and heterosexual men (RR: 0.80, 95% CI 0.69-0.92 and 0.28, 95% CI 0.14-0.59, respectively). Heterosexual men had a greater RR reduction (72% compared with 20% for homosexual men). There was significant heterogeneity among the studies (χ2 = 1378.34, df = 48; I2 = 97%). This meta-analysis shows that male circumcision was effective in reducing HIV risk for both heterosexual and homosexual men.

Fertility preservation in testicular cancer - predictors of spermatogenesis.

OBJECTIVES: To determine the frequency of spermatogenesis in patients with testicular cancer and to assess for any predictors of spermatogenesis. PATIENTS AND METHODS: We retrospectively reviewed 103 testicular germ cell tumours (TGCTs) in men who underwent radical orchidectomy conducted at Guy's Hospital, London, between 2011 and 2015. Primary outcome measures included: the presence and characteristics of spermatogenesis (widespread/focal/proximity to tumour). Secondary outcome measures included: the presence of testicular microlithiasis, tumour characteristics (size, stage, and type), and tumour markers. Secondary outcome measures as potential predictors of spermatogenesis were assessed using univariate and multivariate logistic regression analyses. RESULTS: Spermatogenesis was present in 70% (72/103) of the patients; it was widespread in 63% (45/72) and focal in 38% (27/72). Neither tumour type, stage, presence of microcalcification nor tumour markers predicted spermatogenesis. Men with a percentage testis tumour occupation (PTTO) of >50% of their testis were 82% (95% confidence interval 73.2-98.4) less likely to have spermatogenesis than a PTTO of <50%. CONCLUSIONS: Spermatogenesis is present in most testes affected by TGCTs; it is widespread in two-thirds of patients, and located away from the tumour in 94%. These findings can help predict and guide successful surgical sperm retrieval in testes with TGCTs. The finding of focal spermatogenesis in a third of patients would support a microsurgical approach to sperm retrieval at the time of orchidectomy to maximise success.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - penile amputation.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the British Association of Urological Surgeons (BAUS) Section of Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Penile amputation is a rare genital emergency, which requires prompt intervention and microsurgical reconstruction. The consensus statements will outline the management of these cases for non-specialist units, as well as recommendations for reconstruction for specialists.

BAUS consensus document for the management of male genital emergencies: priapism.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the BAUS Section of Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Priapism requires prompt assessment and treatment and these consensus statements provide guidance for UK practice.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - penile fracture.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. The aim of these consensus statements is to provide best practice guidance for urological surgeons based in the UK which are developed by an expert consensus. Penile fracture is a rare emergency and in most cases requires prompt exploration and repair to prevent erectile dysfunction and penile curvature.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - testicular trauma.

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus comprising British Association of Urological Surgeons (BAUS) Section of Andrology and Genitourethral Surgery together with experts from units throughout the UK. Testicular trauma requires prompt investigation and treatment in order to prevent the development of subfertility or hypogonadism. This series of consensus statements provide guidance for UK practice.

An international survey of contemporary practices towards fertility assessment and preservation in patients undergoing radical inguinal orchidectomy for testicular cancer.

Objective: The study aims to assess current international clinician attitudes, practices and barriers towards fertility assessment and preservation in patients undergoing radical inguinal orchidectomy (RIO) for testicular cancer. Materials and methods: An international online survey of urologists and urologists in training who perform RIO for testicular cancer was developed by the British Association of Urological Surgeons (BAUS) Sections of Andrology and Oncology and the British Urology Researchers in Surgical Training (BURST). The recruitment process used social media and the emailing lists of national urological societies. Responses were collected between 10/02/2021 and 31/05/2021 and stored using password-protected Research Electronic Data Capture (REDCap) database software. The primary outcome was the proportion of urologists who routinely offer semen cryopreservation prior to RIO. The study was reported according to the Checklist for Reporting Results of Internet E-Surveys platform. Results: A total of 393 respondents took part in the online survey; of these, the majority were from the United Kingdom (65.9%), with the remaining international respondents (34.1%) from six different continents, which included 45 different countries. Of the respondents, 57.1% reported that they would routinely offer semen cryopreservation to all patients undergoing RIO for testicular cancer. In addition, 36.0% of urologists routinely performed pre-operative semen analysis, and 22.1% routinely performed pre-operative testicular serum hormone profile. Of the respondents, 14.4% performed expedited RIO within 48 h; 31.2% of respondents reported that they considered no delay to RIO to allow for semen cryopreservation to be acceptable. Conclusions: A significant proportion of international urologists do not offer pre-operative fertility assessment and preservation in men undergoing RIO for testicular cancer. Surgery is performed in an expedited fashion within 1 week in the majority of patients. Urologists perceive there to be a lack of access and availability to fertility services, and that delay to RIO to allow for fertility preservation is often not acceptable.

Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The European Association of Urology guidelines identify lichen sclerosus (LS) as a strong risk factor for penile squamous cell carcinoma (pSCC). However, this statement is based on the findings of case-control studies (Level of Evidence 2a) and a direct causal relationship between LS/balanitis xerotica obliterans (BXO) and pSCC remains to be established. Firm guidelines with respect to the appropriate follow-up policy for LS/BXO are lacking, whereas the impact of synchronous LS/BXO on the prognosis of pSCC remains to be determined. The presence of histologically-confirmed synchronous LS/BXO in patients diagnosed with pSCC is relatively high, although it is not associated with an increased risk of adverse histopathological features. LS/BXO can develop in extragenital skin grafts used for reconstruction after organ-sparing surgery for pSCC. OBJECTIVES: To determine the rate of lichen sclerosus/balanitis xerotica obliterans (LS/BXO) in patients with penile squamous cell carcinoma (pSCC) and establish whether the presence of LS/BXO is associated with adverse histopathological features of pSCC. To report the phenomenon of LS involving non-genital skin grafts in patients who underwent organ-sparing surgery and split-skin graft (SSG) reconstruction PATIENTS AND METHODS: Between January 2002 and January 2010, 223 men underwent surgical treatment for pSCC. A group of 52 patients with histologically-confirmed synchronous LS was identified (group A; overall rate of LS/BXO = 23.3%) and compared with a group of patients without synchronous LS (group B; n = 171; 76.7%). A subgroup of patients who underwent surgical excision and SSG reconstruction was also identified The histology reports of graft biopsies obtained during follow-up were reviewed and the rate of LS involving the graft was also recorded. RESULTS: Mean (range) age at diagnosis was 60.9 (34-81) years and 60.7 (28-89) years for groups A and B, respectively (P = 0.958). The mean (range) duration of follow-up was 38.3 (4-92) months for group A and 45.5 (4-107) months for group B (P = 0.162) No statistically significant differences were noted between groups A and B in terms of tumour grade (P = 0.091), stage (P = 0.697), presence of lymphovascular invasion (P = 0.333), histological subtype (P = 0.107), associated carcinoma in situ (P = 0.246) or nodal status at initial diagnosis (P = 0.555). In the subgroup of 188 patients who underwent SSG reconstruction, 41 (21.8%) patients had histologically-confirmed synchronous LS; in this subgroup, 26 (13.8%) patients underwent graft biopsy during follow-up. Genital LS involving the graft was identified in seven specimens, although none of these seven cases had associated recurrent pSCC. CONCLUSIONS: The presence of histologically-confirmed synchronous LS in patients with pSCC is relatively high but is not associated with increased rates of adverse histopathological features, including carcinoma in situ. LS can develop in extragenital skin grafts, although its association with the long-term risk for recurrent pSCC is not apparent in the present study.

Conservative surgery for squamous cell carcinoma of the penis: resection margins and long-term oncological control.

PURPOSE: We assessed the oncological outcome of penile conserving surgery and identified parameters predicting local recurrence, including resection margins. MATERIALS AND METHODS: A total of 179 patients with invasive penile cancer treated with organ sparing surgery at a tertiary center between 2002 and 2010 fulfilled our study criteria. Demographic, histopathological, management and followup data were recorded in a prospective database. Local, regional and distant recurrence rates, time to recurrence and survival rates were calculated. Survival analysis was performed by the Kaplan-Meier method. Multivariate analysis was used to identify predictors of local recurrence. RESULTS: Mean followup was 42.8 months (range 4 to 107). Local, regional and distant metastatic recurrence developed in 16 (8.9%), 19 (10.6%) and 9 patients (5.0%) at a mean of 26.1, 26.8 and 11.7 months, respectively. The 5-year disease specific survival rate after recurrence was 54.7% (95% CI 46.1-63.3). For patients with isolated local recurrence the 5-year disease specific survival rate was 91.7% compared to 38.4% for those with regional recurrence. The overall 5-year local recurrence-free rate was 86.3% (95% CI 82.6-90.4). Tumor grade (p = 0.003), stage (p = 0.021) and lymphovascular invasion (p = 0.014) were identified as predictors of local recurrence on multivariate analysis. CONCLUSIONS: Penile conserving surgery is oncologically safe and a surgical excision margin of less than 5 mm is adequate. Higher local recurrence rates are associated with lymphovascular invasion, and higher tumor stage and grade. Local recurrence has no negative impact on long-term survival.

Male genital premalignant dermatoses.

The spectrum of conditions affecting the penile skin is varied and ranges from simple, benign dermatoses to premalignant and malignant conditions. Recently, improved understanding of the aetiology and natural history of these conditions has shaped new treatment paradigms and a functional knowledge of dermatology, urology and genitourinary medicine is required to successfully diagnose and treat these men. In this article, we explore the common precancerous states that can lead to penile carcinoma and review the recent advances with regards to the molecular basis for these dermatoses and the treatments that may be most effective for these men.

Protocol for developing a core outcome set for male infertility research: an international consensus development study.

STUDY QUESTION: We aim to develop, disseminate and implement a minimum data set, known as a core outcome set, for future male infertility research. WHAT IS KNOWN ALREADY: Research into male infertility can be challenging to design, conduct and report. Evidence from randomized trials can be difficult to interpret and of limited ability to inform clinical practice for numerous reasons. These may include complex issues, such as variation in outcome measures and outcome reporting bias, as well as failure to consider the perspectives of men and their partners with lived experience of fertility problems. Previously, the Core Outcome Measure for Infertility Trials (COMMIT) initiative, an international consortium of researchers, healthcare professionals and people with fertility problems, has developed a core outcome set for general infertility research. Now, a bespoke core outcome set for male infertility is required to address the unique challenges pertinent to male infertility research. STUDY DESIGN SIZE DURATION: Stakeholders, including healthcare professionals, allied healthcare professionals, scientists, researchers and people with fertility problems, will be invited to participate. Formal consensus science methods will be used, including the modified Delphi method, modified Nominal Group Technique and the National Institutes of Health's consensus development conference. PARTICIPANTS/MATERIALS SETTING METHODS: An international steering group, including the relevant stakeholders outlined above, has been established to guide the development of this core outcome set. Possible core outcomes will be identified by undertaking a systematic review of randomized controlled trials evaluating potential treatments for male factor infertility. These outcomes will be entered into a modified Delphi method. Repeated reflection and re-scoring should promote convergence towards consensus outcomes, which will be prioritized during a consensus development meeting to identify a final core outcome set. We will establish standardized definitions and recommend high-quality measurement instruments for individual core outcomes. STUDY FUNDING/COMPETING INTERESTS: This work has been supported by the Urology Foundation small project award, 2021. C.L.R.B. is the recipient of a BMGF grant and received consultancy fees from Exscentia and Exceed sperm testing, paid to the University of Dundee and speaking fees or honoraria paid personally by Ferring, Copper Surgical and RBMO. S.B. received royalties from Cambridge University Press, Speaker honoraria for Obstetrical and Gynaecological Society of Singapore, Merk SMART Masterclass and Merk FERRING Forum, paid to the University of Aberdeen. Payment for leadership roles within NHS Grampian, previously paid to self, now paid to University of Aberdeen. An Honorarium is received as Editor in Chief of Human Reproduction Open. M.L.E. is an advisor to the companies Hannah and Ro. B.W.M. received an investigator grant from the NHMRC, No: GNT1176437 is a paid consultant for ObsEva and has received research funding from Ferring and Merck. R.R.H. received royalties from Elsevier for a book, consultancy fees from Glyciome, and presentation fees from GryNumber Health and Aytu Bioscience. Aytu Bioscience also funded MiOXYS systems and sensors. Attendance at Fertility 2020 and Roadshow South Africa by Ralf Henkel was funded by LogixX Pharma Ltd. R.R.H. is also Editor in Chief of Andrologia and has been an employee of LogixX Pharma Ltd. since 2020. M.S.K. is an associate editor with Human Reproduction Open. K.Mc.E. received an honoraria for lectures from Bayer and Pharmasure in 2019 and payment for an ESHRE grant review in 2019. His attendance at ESHRE 2019 and AUA 2019 was sponsored by Pharmasure and Bayer, respectively. The remaining authors declare no competing interests. TRIAL REGISTRATION NUMBER: Core Outcome Measures in Effectiveness Trials (COMET) initiative registration No: 1586. Available at www.comet-initiative.org/Studies/Details/1586. TRIAL REGISTRATION DATE: N/A. DATE OF FIRST PATIENT'S ENROLMENT: N/A.

The surgical management of lichen sclerosus of the glans penis: our experience and review of the literature.

INTRODUCTION: Lichen sclerosus (LS) of the glans penis is a chronic, progressive, scleroatrophic inflammatory process of unknown etiology affecting the glans penis, prepuce, and urethra and may lead to severe impairment of sexual and urinary function. AIMS: To report our experience of surgical management of LS of the glans penis. MAIN OUTCOME MEASURES: Complications, patients' satisfaction, cosmesis, resolution of pain and puritus, and postoperative sexual function and were recorded retrospectively. METHODS: The surgical outcome of the 31 patients who have undergone resurfacing of the glans penis with the use of skin grafting for the management of genital LS in our institute is reported. RESULTS: After a median follow-up of 12.8 months, 26 patients (84%) were fully satisfied with cosmetic and functional results, and 71% of them have resumed sexual activity. CONCLUSIONS: Resurfacing of the glans penis represents a simple and reproducible technique for the management of LS and yields excellent functional and cosmetic results.

A Patient-centred Approach to Fertility Management for Testicular Cancer Patients.

Subfertility in testicular cancer is common and often overlooked. Baseline fertility assessments are essential before intervention to allow implementation of a patient-centred pathway to maximise fertility preservation without delaying oncological treatment and to significantly improve a patient's quality of life.

United Kingdom British association for sexual health and HIV national guideline for the management of epididymo-orchitis, 2020.

The British Association for Sexual Health and HIV (BASHH) UK guideline for the management of epididymo-orchitis has been updated in 2020. It offers advice on diagnostic tests, treatment and health promotion principles in the effective management of epididymo-orchitis. Empirical treatment should be started in patients with objective swelling and tenderness on testicular examination. First-line empirical treatment for sexually acquired epididymo-orchitis has changed to ceftriaxone 1g intramuscularly and doxycycline. Higher dose of ceftriaxone in line with the BASHH 2018 gonorrhoea guideline ensures effective treatment of strains with reduced susceptibility. Ofloxacin or doxycycline is recommended in patients with epididymo-orchitis probably due to non-gonococcal organisms (e.g. negative microscopy for gram-negative intracellular diplococci or no risk factors for gonorrhoea identified). Where Mycoplasma genitalium is tested and identified, treatment should include an appropriate antibiotic (e.g. moxifloxacin). If enteric pathogens are a likely cause (e.g. older patient, not sexually active, recent instrumentation, men who practice insertive anal intercourse, men with known abnormalities of the urinary tract or a positive urine dipstick for leucocytes and nitrites), ofloxacin and levofloxacin are recommended. A clinical care pathway has been produced to simplify the management of epididymo-orchitis. A patient information leaflet has been developed.