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Background and Objective: Multiparametric magnetic resonance imaging (mpMRI) of the prostate is used for prostate cancer diagnosis. However, mpMRI has lower sensitivity for small tumours. Prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) offers increased sensitivity over conventional imaging. This study aims to determine whether the diagnostic accuracy of 18F-DCFPyL PSMA-PET/CT was superior to that of mpMRI for detecting prostate cancer (PCa) at biopsy., Methods: Between 2020 and 2021, a prospective multicentre single-arm phase 3 imaging trial enrolled patients with clinical suspicion for PCa to have both mpMRI and PSMA-PET/CT (thorax to thigh), with reviewers blinded to the results of other imaging. Multiparametric MRI was considered positive for Prostate Imaging Reporting and Data System (PIRADS) 3-5. PSMA-PET/CT was assessed quantitatively (positive maximum standardised uptake value [SUVmax] >7) and qualitatively (five-point lexicon of certainty). Patients underwent targeted and systematic biopsy, with the technique at the discretion of the treating urologist. Clinically significant PCa (csPCa) was defined as International Society of Urological Pathology grade group (GG) ≥2. The primary outcome was the diagnostic accuracy for detecting PCa, reported as sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the receiver operating curve. The secondary endpoints included a comparison of the diagnostic accuracy for detecting csPCa, assessing gains in combining PMSA-PET/CT with mpMRI to mpMRI alone., Key Findings and Limitations: Of the 236 patients completing both mpMRI and PSMA-PET/CT, 184 (76.7%) had biopsy. Biopsy histology was benign (n = 73), GG 1 (n = 27), and GG ≥2 (n = 84). The diagnostic accuracy of mpMRI for detecting PCa (AUC 0.76; 95% confidence interval [CI] 0.69, 0.82) was higher than that of PSMA-PET/CT (AUC 0.63; 95% CI 0.56, 0.70, p = 0.03). The diagnostic accuracy of mpMRI for detecting csPCa (AUC 0.72; 95% CI 0.67, 0.78) was higher than that of PSMA-PET/CT (AUC 0.62; 95% CI 0.55, 0.69) but not statistically significant (p = 0.27). A combination of PSMA-PET/CT and mpMRI showed excellent sensitivity (98.8%, 95% CI 93.5%, 100%) and NPV (96%, 95% CI 79.6%, 99.9%) over mpMRI alone (86.9% and 80.7%, respectively, p = 0.01). Thirty-two patients (13.6%) had metastatic disease. They tended to be older (68.4 vs 65.1 yr, p = 0.023), and have higher prostate-specific antigen (PSA; median PSA 9.6 vs 6.2ng/ml, p < 0.001) and abnormal prostate on digital rectal examination (78.2% vs 44.1%, p < 0.001)., Conclusions and Clinical Implications: Multiparametric MRI had superior diagnostic accuracy to PSMA-PET/CT for detecting PCa, though the difference is not significant in case of csPCa detection. A combination of mpMRI and PSMA-PET/CT showed improved sensitivity and NPV. PSMA-PET/CT could be considered for diagnostic use in patients unable to have mpMRI or those with concerning clinical features but negative mpMRI., Patient Summary: In this trial, we compared the ability of 18F-labelled prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) with that of multiparametric magnetic resonance imaging (mpMRI) to diagnose prostate cancer by biopsy in a prostate-specific antigen screening population. We found that MRI was superior to PSMA to diagnose prostate cancer, though there was no difference in ability to diagnose clinically significant prostate cancer. PSMA-PET/CT could be considered for diagnostic use in patients unable to have mpMRI or those with concerning clinical features but negative mpMRI. Combining MRI with PSMA-PET increases the negative predictive value over MRI alone and may help men avoid invasive prostate biopsy., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: The purpose of this study is to evaluate the patient selection methods, treatment outcomes, complications, clinical and radiological follow-up after renal angiomyolipoma (AML) treatment with selective arterial embolization (SAE) in an Australian metropolitan tertiary centre., Methods: This study presents a retrospective single-centre review of patients' medical records who underwent SAE for renal AML during the period of 1st January 2012 and 1st January 2023., Results: A total of 32 SAE procedures for renal AML occurred during the study period. Three episodes were classified as emergency cases [9.38%] and the remaining 29 were treated electively. Mean AML size pre-treatment was 69.45 mm (range = 33-177; SD = 31.69). All AMLs demonstrated hyper-vascularity on contrast-enhanced cross-sectional imaging (arterial-phase enhancement characteristics and/or prominent tortuous feeding vessels) [n = 32; 100%] or an intralesional aneurysm or pseudoaneurysm [n = 12; 42.85%]. Periprocedural complications [n = 3; 9.38%] included: one intralesional haemorrhage after embolization, one vascular access site complication, and one lipiduria-associated urinary tract infection. No patients suffered a life-threatening complication, non-target embolization, deterioration in renal function or death following SAE. Re-treatment with SAE was performed in only three patients [10.71%]. Hospital mean length of stay was 1.58 days. Median durations of clinical and radiological follow-up post-treatment were 493 days (range = 104-1645) and 501 days (range = 35-1774), respectively. Follow-up imaging revealed AML total size reduction in all cases [mean = -17.17 mm; -26.51%] and 50% had obliteration of lesion hyper-vascularity after one episode of SAE. Outpatient clinical follow-up signifies that none of the patients included in the study have re-presented with lesion haemorrhage after successful SAE., Conclusion: In this study, renal AMLs were treated safely with a high degree of success by using SAE, and there were very low rates of periprocedural complications. Follow-up of patients after SAE treatment of renal AML should include both radiological (assessment for reduction in lesion vascularity and size) and clinical review in an outpatient clinic setting (either by an interventional radiologist or urologist)., (© 2024 Royal Australian and New Zealand College of Radiologists.)

Background: Distress is common immediately after diagnosis of testicular cancer. It has historically been difficult to engage people in care models to alleviate distress because of complex factors, including differential coping strategies and influences of social gender norms. Existing support specifically focuses on long-term survivors of testicular cancer, leaving an unmet need for age-appropriate and sex-sensitized support for individuals with distress shortly after diagnosis., Objective: We evaluated a web-based intervention, Nuts & Bolts, designed to provide support and alleviate distress after diagnosis of testicular cancer., Methods: Using a mixed methods design to evaluate the acceptability, feasibility, and impact of Nuts & Bolts on distress, we randomly assigned participants with recently diagnosed testicular cancer (1:1) access to Nuts & Bolts at the time of consent (early) or alternatively, 1 week later (day 8; delayed). Participants completed serial questionnaires across a 4- to 5-week period to evaluate levels of distress (measured by the National Comprehensive Cancer Network Distress Thermometer [DT]; scored 0-10), anxiety, and depression (Hospital Anxiety and Depression Score [HADS]-Anxiety and HADS-Depression; each scored 0-21). The primary end point was change in distress between consent and day 8. Secondary end points of distress, anxiety, and depression were assessed at defined intervals during follow-up. Optional, semistructured interviews occurring after completion of quantitative assessments were thematically analyzed., Results: Overall, 39 participants were enrolled in this study. The median time from orchidectomy to study consent was 14.8 (range 3-62) days. Moderate or high levels of distress evaluated using DT were reported in 58% (23/39) of participants at consent and reduced to 13% (5/38) after 1 week of observation. Early intervention with Nuts & Bolts did not significantly decrease the mean DT score by day 8 compared with delayed intervention (early: 4.56-2.74 vs delayed: 4.47-2.74; P=.85), who did not yet have access to the website. A higher baseline DT score was significantly predictive of reduction in DT score during this period (P<.001). Median DT, HADS-Anxiety, and HADS-Depression scores reduced between orchidectomy and 3 weeks postoperatively and then remained stable throughout the observation period. Thematic analysis of 16 semistructured interviews revealed 4 key themes, "Nuts & Bolts is a helpful tool," "Maximizing benefits of the website," "Whirlwind of diagnosis and readiness for treatment," and "Primary stressors and worries," as well as multiple subthemes., Conclusions: Distress is common following the diagnosis of testicular cancer; however, it decreases over time. Nuts & Bolts was considered useful, acceptable, and relevant by individuals diagnosed with testicular cancer, with strong support for the intervention rendered by thematic analyses of semistructured interviews. The best time to introduce support, such as Nuts & Bolts, is yet to be determined; however, it may be most beneficial as soon as testicular cancer is strongly suspected or diagnosed., (©Ciara Conduit, Christina Guo, Allan B Smith, Orlando Rincones, Olivia Baenziger, Benjamin Thomas, Jeremy Goad, Dan Lenaghan, Nathan Lawrentschuk, Lih-Ming Wong, Niall M Corcoran, Margaret Ross, Peter Gibbs, Sophie O'Haire, Angelyn Anton, Elizabeth Liow, Jeremy Lewin, Ben Tran. Originally published in JMIR Cancer (https://cancer.jmir.org), 28.10.2022.)

Introduction: Prostate-specific membrane antigen positron emission tomography (PSMA-PET) has emerged as valuable imaging to assessing metastatic disease in prostate malignancy. However, there has been limited studies exploring the utility PSMA-PET as primary imaging assessing for index lesions prior to biopsy. The primary objective of this study is to compare the diagnostic accuracy of 18-fluorine PSMA (18F DCFPyL PSMA) PET scans to multiparametric MRI (mpMRI) to detect primary prostate cancer at prostate biopsy., Methods and Analysis: The PEDAL trial is a multicentre, prospective, single-arm, paired comparison, non-randomised phase III trial in subjects considered for diagnostic prostate biopsy. Subjects who are eligible for a diagnostic mpMRI prostate will undergo additional same-day 18 F DCFPyl PSMA PET/CT of the chest, abdomen and pelvis. Software coregistration of the mpMRI and PSMA-PET/CT images will be performed. The reporting of the mpMRI prostate, PSMA-PET/CT and PSMA PET/MRI coregistration will be performed blinded. The diagnostic accuracy of PSMA PET/CT alone, and in combination with mpMRI, to detect prostate cancer will be assessed. Histopathology at prostate biopsy will be used as the reference standard. Sample size calculations estimate that 240 subjects will need to be recruited to demonstrate 20% superiority of PSMA-PET/CT. The sensitivity, specificity, positive predictive value and negative predictive value of the combination of mpMRI prostate and PSMA PET/CT compared with targeted and systematic prostate biopsy will be evaluated. It is hypothesised that PSMA PET/CT combined with mpMRI prostate will have improved diagnostic accuracy compared with mpMRI prostate alone for detection of prostate cancer in biopsy-naïve men, resulting in a significant impact on patient management., Ethics and Dissemination: This study was approved by the independent Human Research Ethics Committee. Results will be published in peer-reviewed medical journals with eligible investigators will significantly contribute., Trial Registration Number: ACTRN12620000261910., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Scaphoid fractures are commonly present to emergency departments (EDs), challenging medical practitioners to achieve accurate diagnosis and management. This is because of the prevalence of radiographically occult scaphoid fractures and complications associated with missed diagnoses. Clinical Guidelines are limited for treatment of suspected scaphoid fractures, and heterogeneity in the literature further complicates management. This study aimed to explore the differences in management between practitioners in the ED and determine if immobilizing clinically suspected scaphoid fractures is supported by current evidence. This study also aimed to establish if there are predictors to assist in the diagnosis of a scaphoid fracture in the ED., Methods: A retrospective cohort study analyzed clinical data from patient's charts who attended the ED for a scaphoid fracture in 2019. Using retrospective patient chart audits and a Data Extraction Form, the clinical data regarding the assessment, treatment, diagnosis, and follow-up outcomes were collected. Descriptive analysis and multivariable logistic regression were performed to assess current management and find out predictors of a scaphoid fracture., Results: There was significance between practitioners performing physical assessments and providing treatment (P < .001). Physiotherapists performed assessment and education combined treatment more frequently than nurse practitioners and doctors. Thirty-four cases (11.7%) were negative for fracture in ED and positive in follow-up at the orthopedic clinic. There was an estimated loss of income of $327,433.60 (Australian dollar) for 221 patients who missed work due to overtreatment with immobilization. The strongest predictors for a confirmed scaphoid fracture were of male gender (odds ratio, 3.2; 95% confidence interval, 2.1-5.0; P < .001) and a positive x-ray in ED (odds ratio, 36.6; 95% confidence interval, 17.4-77.0; P < .001)., Conclusion: Management of scaphoid fractures across the Gold Coast Hospital Health Service ED followed commonly accepted practices involving x-ray and immobilization; however, this conservative approach to management is associated with increased health costs and low rates of conversion to a confirmed scaphoid fracture. Male gender was the only significant predictor associated with a scaphoid fracture., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction and Objectives: Renal calculi are a common medical problem with incidence rates calculated to be approximately 6%-9% in men & 3%-4% in women worldwide. Incidence appears to be increasing. This study compares emergency presentations and unplanned readmissions between extracorporeal shock wave lithotripsy (SWL) and pyeloscopic stone treatment in the population of Victoria, Australia after 1-year follow-up., Methods: This is a population study comparing all patients with renal calculi electively treated with SWL to those initially treated with flexible ureteroscopy (URS) in Victoria, Australia. We used data linkage across the state of Victoria to follow patients treated with either modality in a 12 months period (with no urological surgery in the prior 12 months). Each patient's emergency presentations and subsequent re-admissions were followed up for 1 year after their index treatment to assess for stone complications. We assessed for selection bias between the two patient groups by comparing age, gender, insurance status, geographical location, and comorbidity scores., Results: We report stone-related complications for 739 flexible URS and 1317 SWL procedures undertaken across public and private hospitals in Victoria over 12 months. Unplanned emergency presentations within 60-days of surgery were (22/739) 2.98% for flexible URS patients and (83/1317) 6.30% for SWL patients ( P  = .001); however, at 12 months, this became 16.23% (120/739) for flexible URS patients and 12.83% (169/1317) for SWL patients ( P  = .034). Flexible URS patients were more likely than SWL patients to be admitted with 71.76% of flexible URS versus 53.97% of SWL patients requiring an admission at any given emergency presentation ( P ≤ .001) within 12 months. On multivariate analysis, both flexible URS ([OR] 1.67, CI 1.23-2.26,  P  = .001) and being a public patient ([OR] 3.06, CI 2.24-4.18,  P  < .001) significantly increased the likelihood that patients required an unplanned re-admission within 12 months., Conclusions: There is work needed to reduce emergency presentations and unplanned re-admissions after both SWL and flexible URS. At 12-months follow-up, unplanned emergency visits and re-admission rates were significantly more after flexible URS. Symptoms at emergency presentation indicate that better education regarding stent management is needed, especially in the public health care system., Competing Interests: Gregory Jack, Niall Davis, Matthew Farag, Lih‐Ming Wong: None. Damien Bolton: Boston Scientific, Investigator Grant., (© 2021 The Authors. BJUI Compass published by John Wiley & Sons Ltd on behalf of BJU International Company.)

Objectives: To determine the best way to intervene for ureteric stones which still require treatment during the COVID-19 pandemic, with respect to infection control. In this setting, in which resources are constrained, extracorporeal shockwave lithotripsy (SWL) has prima facie advantages over ureteroscopy (URS). It is also necessary to also consider posttreatment resource consumption in regards to complications and repeat procedures., Subjects and Methods: The ideal ureteric stone treatment during a pandemic such as COVID-19 would involve minimum resource consumption and a minimum number of patient attendances. We compared all patients initially treated with SWL to those initially treated with URS for acute ureteral colic within the state of Victoria, Australia in 2017., Results: A total of 2724 ureteric stones were analyzed, a cumulative "3-month exposure and burden on the healthcare system" was calculated for each patient by their initial procedure type. The readmission rate for URS was significantly higher than for SWL, 0.92 readmissions/patient for URS versus 0.54 readmissions/patient for SWL ( P  < .001). The cumulative hospital stay per patient for these two procedures was 2.35 days for SWL versus 3.21 days for URS ( P  < .001). The number of procedures per patient was 1.52 for SWL versus 1.89 for URS ( P  = .0213)., Conclusions: Patients with ureteric stones treated initially by SWL have shorter length of stay with fewer overall attendances and procedures at 3 months than those treated with URS. During a pandemic such as COVID-19, SWL may have benefits in preserving hospital resources and limiting opportunity for virus transmission, compared to URS., Competing Interests: Dan Lenaghan, Matthew Farag, Lih‐Ming Wong: None; Damien Bolton: Boston Scientific, Investigator Grant; Gregory Jack: Boston Scientific, lecture honoraria., (© 2020 The Authors. BJUI Compass published by John Wiley & Sons Ltd on behalf of BJU International Company.)

Objectives: To evaluate the association between hospital volume and perioperative outcomes of radical cystectomy (RC) using state population data for a contemporary Australian cohort., Patients and Methods: Patients undergoing RC for urothelial malignancy in the state of Victoria, Australia between July 2003 and June 2014 were identified using the Victorian Admitted Episodes Dataset (VAED). Hospitals were divided into tertiles according to their caseload per year. Hospitals performing <4 RCs/year were defined as low-volume hospitals (LVH), 4-10 RCs/year as medium-volume hospitals (MVH), and >10 RCs/year as high-volume hospitals (HVH). Perioperative outcomes derived included: in-hospital mortality (IHM), prolonged length of stay (LOS; >14 days), prolonged intensive care unit (ICU) admission (>24 h), and requirement for blood transfusion. The relationship between hospital volume and perioperative outcomes was assessed using logistic regression., Results: During the 11-year study period, 803 patients underwent RC for bladder cancer. The overall IHM rate was 2.2% (LVH 3.7%, MVH 2.5%, HVH 0.9%). Other outcomes observed were prolonged LOS (45%), prolonged ICU admission (31%) and requirement for blood transfusion (56%). On multivariate analysis, LVH was found to be associated with increased IHM (odds ratio [OR] 5.74, P = 0.04) and prolonged ICU admission (OR 11.58, P < 0.001) when compared to HVH. There was a lower rate of prolonged LOS for LVH (OR 0.60, P = 0.01). No significant relationship was identified for LVH and blood transfusion., Conclusion: Perioperative outcomes in Victoria are comparable to international standards. Our results add further population study evidence to the volume-outcome relationship in RC. There was a significant association between LVH and both IHM and prolonged ICU admission. This subgroup of patients would appear to benefit from transfer of care to a HVH. The role of centralisation of RC in Australia should be further considered., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Type 1 diabetes mellitus (T1D) is a chronic autoimmune disease characterized by beta cell destruction, insulin deficiency and hyperglycemia. Activated macrophages and autoimmune T cells play a crucial role in the pathogenesis of hyperglycemia in NOD murine diabetes models, but the molecular mechanisms of macrophage activation are unknown. We recently identified pigment epithelium-derived factor (PEDF) as an adipocyte-derived factor that activates macrophages and mediates insulin resistance. Reasoning that PEDF might participate as a proinflammatory mediator in murine diabetes, we measured PEDF levels in NOD mice. PEDF levels are significantly elevated in pancreas, in correlation with pancreatic TNF levels in NOD mice. To identify experimental therapeutics, we screened 2,327 compounds in two chemical libraries (the NIH Clinical Collection and Pharmakon-1600a) for leads that inhibit PEDF mediated TNF release in macrophage cultures. The lead molecule selected, "emetine" is a widely used emetic. It inhibited PEDF-mediated macrophage activation with an EC50 or 146 nM. Administration of emetine to NOD mice and to C57Bl6 mice subjected to streptozotocin significantly attenuated hyperglycemia, reduced TNF levels in pancreas, and attenuated insulitis. Together, these results suggest that targeting PEDF with emetine may attenuate TNF release and hyperglycemia in murine diabetes models. This suggests that further investigation of PEDF and emetine in the pathogenesis of human diabetes is warranted.

This article describes a case of anaphylaxis secondary to chlorhexidine during urethral catheterisation. Despite little evidence for the use of antiseptic lubricants in preventing catheter-associated urinary tract infections, the distribution and use of such products continues to be widespread. Chlorhexidine-free lubricating gel is widely available and should be used for urological procedures wherever possible.

Purpose: To assess the diagnostic reliability of a dichotomous digital rectal examination (DRE) tool in assessing prostate volume (PV) compared to gold-standard transrectal ultrasound (TRUS) volume measurement., Materials and Methods: Male patients presenting to a single tertiary referral centre urology practice requiring TRUS were prospectively recruited between January 2010 and August 2011. Size was estimated by DRE immediately prior to TRUS measurement. DRE measurements were classed into four groups: <30 mL , 30 to 49 mL, 50 to 99 mL and >100 mL. The primary outcomes were sensitivity, specificity, and the positive and negative likelihood ratios for a 30 mL cut-off., Results: Three hundred and three patients were recruited to the study. The median age of the study group was 64.9 years. On TRUS analysis, 244 patients had a PV larger than 30 mL and 139 of them, larger than 50 mL. The median PV was 47 mL with a median International Prostate Symptom Score of 10 and prostatic specific antigen (PSA) of 5.7. When analysed for the ability to identify a gland larger than 30 mL, DRE had a high sensitivity and low negative likelihood ratio. The median PSA level (ng/L) for prostates measured by DRE with a 30 mL cut-off was significantly different with higher median PSA values for volumes larger than 30 mL., Conclusions: DRE is a reliable tool for dichotomous assessment of prostatic volumes above 30 mL and 50 mL. These results illustrate the value of re-examining the role of categorical DRE estimations in benign prostatic hyperplasia patients.

The results obtained in 37 patients treated by partial cystectomy and 51 patients treated by total cystectomy are presented. Partial cystectomy was usually performed for deeply invasive tumours. THere were no operative deaths, but 85% of the patients died in the first two years of follow-up and the five-year survival was 11%. Of the 51 patients having total cystectomy, 22 were operated upon after other treatments had failed. There were six (11.8%) operative deaths, only one following simple cystectomy, and the remainder following radical cystectomy with or without urethrectomy. Almost half the survivors died in the first two years, and the five-year survival was 31%. The better prognosis in total cystectomy is attributable to the presence of a number of patients with multicentric but relatively non-invasive tumours. Thirteen patients, all with invasive bladder tumours, had 4,000 R irradiation to the pelvis before operation. There was no benefit demonstrated in this combined treatment. The loss survival rate despite treatment in deeply invasive bladder tumours indicates the value of early diagnosis and the need for more effective forms of treatment.

Spontaneous cessation of vesicoureteral reflux occurred in 42 per cent of 102 patients. It ceased in 65 per cent of the patients with unilateral reflux, in 50 per cent of those with bilateral reflux in normal caliber ureters and in 9 per cent of those with bilateral dilated ureters. Renal parenchymal changes were seen most frequently in patients with urinary infection after diagnosis. The likelihood of such infections lessened if reflux ceased. Proportionately more male than female subjects were free of infection. Renal damage may follow even 1 episode of infection. Lesions appeared with equal frequency during the entire followup period, whereas urinary infection was more common in the 5-year period after diagnosis. Renal damage was more likely to occur in kidneys that were already abnormal. Reflux should be controlled surgically if urinary infections occur after diagnosis and during long-term chemotherapy and careful observation. In the absence of infection indications for operation are infrequent. Non-surgical management may apply to normal caliber ureters and in infancy, while antireflux operation may be considered at diagnosis in dilated ureters, bilateral reflux or in the presence of renal lesions.

Ureteric obstruction resulting from retrocaval ureter may be due to either compression of the ureter by the vena cava or stenosis of the postcaval segment. If obstruction is due to stenosis, the commonly described operation of division and anastomosis through the proximal dilated ureter or pelvis, after repositioning of the ureter, is likely to fail, as is division of the vena cava itself. Excision of the postcaval segment with anastomosis of the spatulated ureter over a Silastic splint is therefore recommended. Three case histories of patients with retrocaval ureter treated surgically are presented and support this view.