Background and Objective: Surgical management of bladder outflow obstruction (BOO) caused by benign prostatic enlargement (BPE) has proven challenging, with increased pressure on National Health Service (NHS) resources. Traditionally, transurethral resection of prostate (TURP) was performed requiring an average inpatient stay of 2-4 days. If complications occur, the patient's stay in the urology ward is extended. Limited bed availability can result in the cancellation of elective surgeries. This continues to pose a challenge with the surge of COVID and respiratory infections during the winter season, resulting in a very limited bed availability. In recent decades, multiple new interventions for bladder outflow obstruction have emerged and proven safe and efficacious in multiple large studies. Our study's aim was to demonstrate GreenLight Laser Prostatectomy's (GLLP) feasibility as a 'true' day-case procedure. Materials and methods: Data collection for both GLLP and bipolar TURP was done as a retrospective observational cohort study in a single institution. Both cohorts underwent primary operation; primary GLLP cases were performed in 2021/2022, and primary bipolar TURP between 2023/2024. Greenlight laser prostatectomy was performed using the 180 W GreenLight XPS (TM) laser therapy system, and bipolar TURP using standard Olympus/Richard Wolf resectoscopes. Multiple preoperative, operative, and postoperative parameters were collected, with a primary focus on day-case discharge after the procedure. Results: A total of 180 patients underwent bladder outflow surgery, of which 90 patients (50%) had GLLP and the other 90 patients (50%) had TURP. The mean age for the GLLP group was 73.9 and for the TURP group was 71.9. We have observed a statistically significant difference in prostate volume between the two groups, with a mean volume of 98.9 cc for the GLLP group and 76.9 cc for the TURP group (p = 0.01). Even though prostates in the GLLP group were larger in size, the operation time was significantly shorter in the GLLP group, with a mean of 57.3 minutes, compared to 66.9 minutes for TURP (p = 0.01). In terms of hospital stay postoperatively, we observed a significant difference in the day-case discharge rate: 94.4% of patients in the GLLP group were discharged as day cases compared to only 4.4% in the TURP group (p < 0.001). Both the GLLP group (72 participants, 80%) and the TURP group (83 participants, 92.2%) achieved successful Trial to Void Without Catheter (TWOC), representing a significant difference in favour of TURP (p = 0.018). A survey regarding the patients' experience was conducted with the operative and postoperative processes has shown that 71.1% of participants in the GLLP group were satisfied, compared to 51.1% in the TURP group, which was statistically significant in favour of the GLLP (p < 0.001). Conclusion: Based on our observations, GLLP is a safe day-case operation with a good patient satisfaction rate and an acceptable success rate. It effectively addresses bladder outflow issues in hospitals with limited bed capacity. When implemented via a well-designed pathway, it can help reduce the waiting times in the NHS.
This study attempts to determine whether midwall myocardial fibrosis burden is associated with adverse clinical outcomes in asymptomatic patients and whether those with more fibrosis derive greater benefit from early intervention. QuestionIn asymptomatic patients with severe aortic stenosis, is myocardial fibrosis burden associated with adverse events and potential benefits of early valve intervention?FindingsIn this post hoc analysis of a randomized clinical trial, higher midwall fibrosis burden was associated with increasing incidence of the primary composite end point of all-cause death or unplanned aortic stenosis-related hospitalization. However, the potential beneficial effects of early valve intervention demonstrated no significant heterogeneity by the degree of midwall fibrosis.MeaningIn this study, in asymptomatic patients with severe aortic stenosis, higher fibrosis burden was associated with adverse outcomes; benefits of early intervention were similar between patients with high and low fibrosis burden. ImportanceMyocardial fibrosis burden has been associated with adverse clinical outcomes in symptomatic patients with aortic stenosis.ObjectiveTo determine whether midwall myocardial fibrosis burden is associated with adverse clinical outcomes in asymptomatic patients and whether those with more fibrosis derive greater benefit from early intervention.Design, Setting, and ParticipantsThis post hoc analysis of a randomized clinical trial was conducted between August 2017 and October 2022. The trial took place at 24 cardiac centers across the United Kingdom and Australia. Participants included asymptomatic patients with severe aortic stenosis and midwall fibrosis on cardiac magnetic resonance. These data were analyzed from October 2024 through June 2025.InterventionEarly intervention with transcatheter or surgical aortic valve replacement.Main Outcomes and MeasuresPrimary outcome was all-cause death or unplanned aortic stenosis-related hospitalization. Secondary outcomes included the individual components of the primary outcome.ResultsIn 224 trial participants (mean [SD] age, 73 [9] years; 63 women and 161 men, and mean [SD] aortic valve peak velocity 4.3 [0.5] m per second) with a median follow-up of 42 months, fibrosis burden (per 1% increase) was associated with an increase in the primary end point (hazard ratio [HR], 1.23; 95% CI, 1.08-1.37) and its component of unplanned aortic stenosis-related hospitalizations (HR, 1.22; 95% CI, 1.03-1.40) but not all-cause death (HR, 1.17; 95% CI, 0.98-1.35). There were no interactions between randomization arm and the midwall fibrosis burden for the primary (P for interaction = .39) or secondary end points. In patients with high fibrosis burden above the median, the primary end point occurred in 12 of 59 (20%) of those randomized to early intervention and 17 of 53 (32%) of those randomized to guideline-directed conservative management (HR, 0.62; 95% CI, 0.29-1.28). For the individual components, all-cause death occurred in 9 (15%) and 10 (19%) patients, respectively (HR, 0.84; 95% CI, 0.33-2.07), and unplanned aortic stenosis-related hospitalization in 4 (7%) and 13 (25%) patients respectively (HR, 0.27; 95% CI, 0.08-0.77). In patients with low fibrosis burden below the median, there were no differences in the primary outcome (HR, 1.05; 95% CI, 0.39-2.86) or its components between intervention groups.Conclusions and RelevanceIn this study, in asymptomatic patients with severe aortic stenosis, higher midwall fibrosis burden was associated with adverse outcomes. There was no demonstrable heterogeneity by the degree of midwall fibrosis for the treatment effects of early surgical or transcatheter aortic valve replacement compared to clinical surveillance.Trial RegistrationClinicalTrials.gov Identifier: NCT03094143
Introduction Pleural mesothelioma (PM) is often presaged by benign asbestos-associated pleural inflammation (AAPI), offering a unique window of opportunity for translational research. The PREDICT-Meso International Accelerator Network is leveraging this natural history to perform target identification and develop novel therapies for early-stage or pre-invasive disease. This requires assembly of a unique bioresource of longitudinal human tissue samples spanning the terminal stages of PM evolution, development of preclinical models for drug screening and reliable tools for risk prediction in patients presenting with AAPI.Methods and analysis Mesothelioma Observational study of Risk prediction and Generation of paired benign-meso tissue samples, Including a Nested MRI Substudy (Meso-ORIGINS) is a prospective, multicentre observational study, comprising two arms (A and B), with a nested MRI substudy in arm A. Arm A will recruit 300 AAPI patients and perform 6-monthly surveillance for 2 years. Suspicion of PM evolution will prompt repeat biopsy and banking, delivering a primary objective of ≥38 longitudinal AAPI-PM tissue pairs. This target reflects a projected PM evolution rate of 14% (95% CI 10.5 to 19.2) derived from a prior multicentre feasibility trial. Multiomic risk profiling will be performed in arm A, using blood proteomics, exhaled breath metabolomics and perfusion MRI. Arm B will recruit 300 patients with suspected PM, permitting collection of multiregion pleural biopsies in patients spanning AAPI and PM timepoints for evaluation of anatomical heterogeneity. Where possible, patients in arm B diagnosed with AAPI will be recruited to arm A for 2-year surveillance +/− repeat biopsy in subsequent PM evolution cases. Pleural fluid will be collected in arm B for cell-line generation and diagnostic biomarker evaluation. Exhaled breath will be collected in arm B for diagnostic biomarker evaluation.Ethics and dissemination The study has ethical approval (REC Ref 21/WS/0120). Results will be disseminated via peer-reviewed journals and national/international scientific conferences. Tissues, data and derived omics will be shared via the PREDICT-Meso Research Tissue Bank (REC Ref 21/WS/0011).Trial registration number ISRCTN22929761.
Introduction Serious and life-threatening complications can occur from the delayed removal of biliary stents. A robust system is needed to ensure the timely removal of stents. We aimed to evaluate our practice of using a stent register to remove stents on time and identify system failures that contribute to missed stent removals. Method A new electronic stent register was introduced in our endoscopy service of a busy district general hospital under the National Health Service (NHS) in the United Kingdom. This register was initiated to support the tracking of patients who had biliary stents placed to ensure that this is removed on time. We analysed the usefulness of our register in managing patients who had a biliary stent placed. Data was extracted from the database after a 20-month data collection period. Collected data included stent type and follow-up plans. The electronic record was examined for clinical course and evidence of removal. Results Over the study period, 414 patients underwent endoscopic retrograde cholangiopancreatography (ERCP), and 89 patients had stents placed. After clinical review, 82 cases were managed appropriately. In seven cases, stents were overdue for removal. The reasons for delay were: patient preference (n=1); relocation out of area (n=2); and inadequate follow-up (n=4). The register also identified patients with oesophageal and lumen-apposing metal stents, all of whom had appropriate follow-up and removal plans documented. Conclusion Inadequate follow-up documentation and unclear responsibility for ongoing surveillance were identified in the majority of genuinely overdue cases. Implementation of an electronic stent register successfully identifies patients with overdue stent removal or exchange. Successful implementation of a stent register requires regular clinical oversight and consistent staff engagement.
BACKGROUND:Transdermal estradiol (tE2) is an alternative to luteinizing hormone-releasing hormone (LHRH) agonists as androgen-deprivation therapy in patients with prostate cancer. With tE2, testosterone is suppressed, and the side effects of estrogen depletion due to LHRH agonists and the thromboembolic side effects of oral estrogen are mitigated. METHODS:In this phase 3, noninferiority, randomized trial, we assigned men with locally advanced (M0 and N0 or N+) prostate cancer to receive tE2 patches (100 μg of estradiol every 24 hours) or LHRH agonists. The primary outcome was 3-year metastasis-free survival. The noninferiority margin was 4 percentage points; this corresponded to a target hazard ratio of 1.31, as derived from the observed 3-year metastasis-free survival in the LHRH agonist group. Secondary outcomes included castrate levels of testosterone (<1.7 nmol per liter), overall survival, and safety. RESULTS:Between 2007 and 2022, we recruited 1360 patients at 75 U.K. centers. The median age of the patients was 72 years (interquartile range, 68 to 77); 85% had a T3 tumor stage and 65% an N0 nodal stage. Observed 3-year metastasis-free survival was 87.1% with tE2 and 85.9% with LHRH agonists (hazard ratio for confirmed metastasis or death, 0.96; upper limit of the one-sided 95% confidence interval [CI], 1.11, which met the criterion for noninferiority). Among patients continuing the assigned treatment, castrate levels of testosterone were sustained during the first year after randomization in 85% in each group. Observed 5-year overall survival was 81.1% with tE2 and 79.2% with LHRH agonists (hazard ratio for death, 0.90; 95% CI, 0.75 to 1.07). During treatment, hot flashes occurred in 44% of the patients who received tE2 and 89% of those who received LHRH agonists (grade ≥2 events, 8% and 37%, respectively) and gynecomastia in 85% and 42% (grade ≥2 events, 37% and 9%). CONCLUSIONS:In patients with locally advanced prostate cancer, tE2 was noninferior to LHRH agonists for 3-year metastasis-free survival, with a lower incidence of hot flashes but a higher incidence of gynecomastia. (Funded by Cancer Research U.K. and the U.K. Research Institute Medical Research Council; PATCH ClinicalTrials.gov number, NCT00303784; STAMPEDE-1 ClinicalTrials.gov number, NCT00268476.).
