Objectives: To understand the clinical characteristics, risk factors, diagnosis, treatment, and outcomes of urinary tract obstruction caused by fungal balls. Materials and Methods: A comprehensive search was conducted across PubMed, Embase, and Medline following the PRISMA guidelines, including case reports and case series. Study quality and risk of bias were assessed using the Oxford Centre for Evidence-Based Medicine (CEBM) document. The systematic review process was aimed at gathering and synthesising all available research evidence on the topic. Results: We included 54 articles reporting on 57 patients, primarily males (61.4%) with a median age of 56 years. The most common presenting symptoms were flank pain (71.9%) and fevers (59.6%). All diagnoses were made on the presence of yeast in urine or intra-operative tissue cultures and the presence of obstruction on imaging. The most common pathogen isolated were those of the Candida species (61.5%) followed by Aspergillus (33.3%). Multimodal management was the mainstay approach with the use of systemic and local antifungal therapy in combination with surgical drainage of the obstruction. The mortality rate was around 12.3%. Conclusions: Management of renal or ureteral obstruction caused by fungal balls requires a multimodal and multidisciplinary approach, comprising systemic antifungal therapy, drainage procedures, and in some instances, surgical intervention. The growing prevalence of antifungal resistance and the high mortality potential of fungal uropathy necessitates ongoing research into the optimal diagnostic and treatment modalities for this condition.

BACKGROUND:Stereotactic ablative body radiotherapy (SABR) is a novel non-invasive alternative for patients with primary renal cell cancer who do not undergo surgical resection. The FASTRACK II clinical trial investigated the efficacy of SABR for primary renal cell cancer in a phase 2 trial. METHODS:This international, non-randomised, phase 2 study was conducted in seven centres in Australia and one centre in the Netherlands. Eligible patients aged 18 years or older had biopsy-confirmed diagnosis of primary renal cell cancer, with only a single lesion; were medically inoperable, were at high risk of complications from surgery, or declined surgery; and had an Eastern Cooperative Oncology Group performance status of 0-2. A multidisciplinary decision that active treatment was warranted was required. Key exclusion criteria were a pre-treatment estimated glomerular filtration rate of less than 30 mL/min per 1·73 m2, previous systemic therapies for renal cell cancer, previous high-dose radiotherapy to an overlapping region, tumours larger than 10 cm, and direct contact of the renal cell cancer with the bowel. Patients received either a single fraction SABR of 26 Gy for tumours 4 cm or less in maximum diameter, or 42 Gy in three fractions for tumours more than 4 cm to 10 cm in maximum diameter. The primary endpoint was local control, defined as no progression of the primary renal cell cancer, as evaluated by the investigator per Response Evaluation Criteria in Solid Tumours (version 1.1). Assuming a 1-year local control of 90%, the null hypothesis of 80% or less was considered not to be worthy of proceeding to a future randomised controlled trial. All patients who commenced trial treatment were included in the primary outcome analysis. This trial is registered with ClinicalTrials.gov, NCT02613819, and has completed accrual. FINDINGS:Between July 28, 2016, and Feb 27, 2020, 70 patients were enrolled and initiated treatment. Median age was 77 years (IQR 70-82). Before enrolment, 49 (70%) of 70 patients had documented serial growth on initial surveillance imaging. 49 (70%) of 70 patients were male and 21 (30%) were female. Median tumour size was 4·6 cm (IQR 3·7-5·5). All patients enrolled had T1-T2a and N0-N1 disease. 23 patients received single-fraction SABR of 26 Gy and 47 received 42 Gy in three fractions. Median follow-up was 43 months (IQR 38-60). Local control at 12 months from treatment commencement was 100% (p<0·0001). Seven (10%) patients had grade 3 treatment-related adverse events, with no grade 4 adverse events observed. Grade 3 treatment-related adverse events were nausea and vomiting (three [4%] patients), abdominal, flank, or tumour pain (four [6%]), colonic obstruction (two [3%]), and diarrhoea (one [1%]). No treatment-related or cancer-related deaths occurred. INTERPRETATION:To our knowledge, this is the first multicentre prospective clinical trial of non-surgical definitive therapy in patients with primary renal cell cancer. In a cohort with predominantly T1b or larger disease, SABR was an effective treatment strategy with no observed local failures or cancer-related deaths. We observed an acceptable side-effect profile and renal function after SABR. These outcomes support the design of a future randomised trial of SABR versus surgery for primary renal cell cancer. FUNDING:Cancer Australia Priority-driven Collaborative Cancer Research Scheme.

This study assessed the acceptability and feasibility of a question prompt list (QPL) to facilitate informed treatment decision-making in men with suspected localised prostate cancer, which involves values-based choices between options with similar efficacy but different side effects. The QPL was developed through iterative consultation with consumers, clinicians and researchers. Acceptability was assessed using study-specific questions regarding QPL satisfaction and usefulness and qualitative interviews. Feasibility was determined via the proportion of men given the QPL according to medical records and the completion of standardised measures of decisional outcomes. Quantitative data were analysed using descriptive and univariate statistics. Qualitative data were thematically analysed. Fifty-two men consented; 34 provided data for analysis. The QPL recipients reported moderate-high content satisfaction (70.6%) and perceived usefulness in guiding appointments when receiving biopsy results (64.7%). Two main qualitative themes also indicated the QPL acceptability: (1) the freedom to ask-acceptable timing, flexible usage and usefulness of the QPL, and (2) satisfaction with the QPL content. However, only 18.4% of eligible men received the QPL, indicating limited feasibility. The QPL is safe and acceptable, but further research is needed regarding how to facilitate the uptake of the question prompt list in clinical practice.

Floseal Hemostatic Matrix is a topical hemostatic agent used across specialties and commonly applied to the renal bed during partial nephrectomy. Here we present the first adult case of Floseal allergy in the literature. A 62-year-old man underwent partial nephrectomy for a Bosniak type IV cyst. After unclamping the kidney, the patient declined precipitously, later determined due to an anaphylactic reaction to the Floseal placed on the renal bed. The patient had a prolonged anaphylactic reaction that required ionotropic support for over 24 h, possibly due to continued exposure. His tryptase level was elevated, and allergy testing revealed an allergy to the gelatin matrix component of the Floseal. Floseal anaphylaxis should be considered during episodes of cardiovascular collapse after drug administration. However, consideration should be given to removing it to prevent continued exposure and weighed against the risk of prolonged surgery in an anaphylactic patient.

BACKGROUND:Decisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC).METHODS:Quantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests.RESULTS:Most participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P < 0.001) after the CC. Mean decisional regret scores were 'mild' at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion.CONCLUSION:This is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings.

Background: Benign prostatic hyperplasia is the most common urological condition affecting quality of life in men. Its incidence increases proportionally with age and typically manifests with mixed lower urinary tract symptoms. Giant prostatic hyperplasia, the most extreme form of BPH, can present with more serious clinical consequences and presents a challenge to surgical management. Case presentation: We present the first reported case of provoked deep vein thrombosis and near fatal pulmonary embolus from a symptomatic megaprostate exerting pelvic mass effect on the external iliac vein, further complicated by haematuria post catheter-directed thrombolysis. Conclusion: This case highlights the success of prostate artery embolization and catheter-directed thrombolysis to treat potential sequelae of giant prostate hyperplasia.

ObjectivesTo assess the role of music in reducing the pain and anxiety associated with flexible cystoscopy using a blinded trial design.Patients and MethodsA patient‐blinded randomised control trial of music during flexible cystoscopy was performed comparing the pain, measured by visual analogue scale (VAS), anxiety, measured by the State‐Trait Anxiety Inventory (STAI), and vital signs of 109 patients across two public hospitals in New South Wales, Australia. The purpose and hypothesis of the study was concealed from patients until after results had been collected.ResultsThere were no statistically significant differences detected between the No Music and Music groups in VAS pain score (mean [SD] 2.04 [1.94] vs 2.10 [1.90], P = 0.86), change in STAI anxiety score (mean [SD] 4.87 [9.87] vs 6.8 [11.07], P = 0.33) or post‐procedural vital signs (mean [SD] heart rate 74 [14] vs 72 [13] beats/min, P = 0.66; systolic blood pressure 144 [20] vs 141 [19] mmHg, P = 0.47) between the two groups.ConclusionMusic does not appear to decrease perceived pain or anxiety when used during flexible cystoscopy. These findings may differ from the literature due to several factors, most significantly blinding of participants, but also potentially due to the ethnic composition of the study population or lack of choice of music.

BACKGROUNDS:The COVID-19 pandemic is an unprecedented threat to health and healthcare systems. There is no published data on the impact on urological presentations in Australia.METHODS:A retrospective analysis of all admissions under the urology service at Liverpool Hospital, Australia from February 1st to April 30th for 2020 and the previous 5 years.RESULTS:There was a total of 397 admissions in 2020 and 438 in 2019. The mean age, proportion of male, and mean length of stay were similar. In 2020, there were 229 emergency admissions. Over the same period during the previous 5 years, there were between 195 and 218 emergency admissions. In 2019, there were 220 planned admissions and 168 in 2020. Between 2019 and 2020, there was no significant difference in the proportion of patients with admission longer than 10 days (P = 0.602), requiring intensive care unit admission (P = 0.708) or inpatient operative management (P = 0.171). Among the emergency admissions, the mean Charlson Comorbidity Index was significantly lower in 2020 compared to 2019 (P = 0.009).CONCLUSIONS:Despite the pervasive fear of the COVID-19 pandemic and multiple, substantial alterations to hospital systems, structures and elective operating restrictions, no significant difference in numbers or acuity of emergency admissions were observed. Due to limitations in elective operating, there was an expected reduction in planned admissions. Our findings are in contrast to multiple recent studies and may be the result of our patient demographic where health-seeking behaviours appear to have not been significantly influenced by the pandemic.

Objective: Surgical procedures assisted by robotic technology have been increasing in uptake, particularly in private hospitals.Unlike most of the studies on robotic technology which were sponsored by pecuniary interests of the dominant Monopoly supplier, this paper is an independent investigators' initiated study of comparative health system costs in a Local Health District on Robotic Surgery (RS) versus Non-RS for patients undergoing prostatectomy amongst a cohort of public patients.The report was limited to understanding the cost implications of RS and productivity savings associated with it via consistently reduced length of stay (LOS).Patient benefits were not formally measured or assessed.Methods: Estimated marginal costs of both RS and Non-RS were ascertained via cost modelling Activity Based Funding (ABF) cost bucket categories for each inpatient separation for Non-RS radical prostatectomy and comparing these to actual costs for patients undergoing RS for radical prostatectomy.This approach compared the expected non-theatre costs of both RS and Non-RS, and considered appropriate cost bucket comparators for operating theatre costs.Results: The results are in congruence with established literature, RS costs are higher than Non-RS.Specifically, this study found that RS yielded a productivity saving to the health system of two days shorter LOS, than Non-RS.However, the marginal cost per separation of RS prostatectomy is $3086 higher than Non-RS prostatectomy in the instruments and consumables costs.Any potential savings associated with reduced LOS do not offset the higher marginal costs associated with RS.Conclusion: Instruments and consumables for RS remain as monopoly products, save for

In this case report we explore the clinical journey of a 66-year-old female patient that developed a uretero-duodenal fistula. This urological complication is extremely rare and to our knowledge, this is only the third female described in the literature with this finding. We discuss the risk factors associated with uretero-duodenal fistula and its management in the acute setting.

Amyloidosis is a group of disorders characterized by the extracellular deposition of amorphous, misfolded proteins.Primary localized bladder amyloidosis is a rare form of the disease that usually presents with macroscopic hematuria, irritative lower urinary tract symptoms, or a bladder mass on imaging.Presented herein is a case of a 76-year-old female who presented with sepsis, distal ureteric calculus, and chronic ureteric obstruction without the classical symptoms of bladder amyloidosis.Cystoscopic resection of thickened bladder wall was positive for amyloid deposition with no signs of malignancy.

Objective: To understand how best to support men diagnosed with localised prostate cancer to decide which treatment option best suits their needs, when robotic prostatectomy and radiotherapy are equally appropriate to offer them. Methods: Twenty-five men recently diagnosed with localised prostate cancer completed semi-structured interviews asking about information/decision-making needs before and/or after attending a combined clinic in which they consulted a urologist and a radiation oncologist regarding treatment options. Data was transcribed verbatim and thematically analysed. Results: Most men preferred robotic prostatectomy pre-combined clinic and chose it afterwards. The thematic analysis revealed four themes: 1) trust in clinicians and the information they provide is critical for treatment choice, 2) perceived fit between treatment characteristics and personal circumstances, 3) additional considerations: specific side effects, socio-emotional and financial factors, and 4) need for tailored information delivery. Robotic prostatectomy was mistakenly believed to provide a more definitive cure than radiotherapy, which was seen as having a lesser lifestyle impact. Conclusions: Treatment choice is largely dependent on clinicians' (mainly urologists') recommendations. Practice implications: Patients need more balanced information about alternatives to robotic prostatectomy earlier in the treatment decision-making process. Referral to a radiation oncologist or combined clinic shortly after diagnosis is recommended. (C) 2019 Elsevier B.V. All rights reserved.

Background Current guidelines highlight the importance of accurate staging in the management and prognostication of high risk primary prostate cancer. Conventional radiologic imaging techniques are insufficient to reliably detect lymph node metastases in prostate cancer. Despite promising results, there is limited published data on the diagnostic accuracy of PSMA PET-CT to assess local nodal metastases prior to radical prostatectomy. This study aims to assess the diagnostic efficacy of 68Ga PSMA PET-CT in local lymph node staging of high risk primary prostate cancer when compared to histopathological findings following radical prostatectomy with pelvic lymph node dissection. Methods We retrospectively analysed consecutive patients with high risk primary prostate cancer referred by urologists for primary staging PSMA PET-CT using a 68Ga-labeled PSMA ligand, Glu-NH-CO-NHLys-(Ahx)-[HBEDD-CC], from October 2015 to October 2017. The scans of patients who underwent radical prostatectomy with pelvic lymph node dissection were interpreted by the consensus reading of two experienced nuclear medicine physicians blinded to clinical and histopathological data. The contemporaneous records of the referring urologists were retrospectively reviewed for noteworthy unexpected PET findings that altered their personal preference for surgical management. Results Seventy-one patients were recruited and analysed. PSMA PET-CT showed findings compatible with local disease in 47 patients (66.2%), lymph node metastases in 10 patients (14.1%) and distant metastases in 14 patients (19.7%). Twenty-eight patients (twenty-seven of whom had local disease only) underwent surgery yielding 214 lymph nodes, all of which were negative on histopathological analysis. On a node-based analysis, 213 of 214 lymph nodes were accurately identified as negative for disease with a negative predictive value of 100%. 11 patients had unexpected PET findings contemporaneously documented by urologists to alter their preference for surgical management. Conclusions PSMA PET-CT appears to have a high negative predictive value for local lymph node metastases in high risk primary prostate cancer when compared to histopathological findings following radical prostatectomy with pelvic lymph node dissection.

multivariable prognostic model PREDICT Prostate -derived from high quality survival data and validated in 3 PCa cohorts (including >80,000 men).We then reviewed current treatment practices, and assessed what impact PREDICT Prostate would have on these.METHODS: Study materials were managed using Qualtrics research software (Utah, USA).Participation of PCa specialists was requested predominantly through professional mailing lists.Respondents were randomised into group A or B and presented with opposing hypothetical vignettes: 6 with clinical diagnostic information only and 6 with these details plus PREDICT Prostate estimates.Comparisons were made between groups for clinician-estimated and model-predicted 15-year outcomes.Data analyses were performed using Stata 14 (Texas, USA).RESULTS: 190 responses were received.63.7% and 16.8% of respondents were urologists and oncologists respectively.59.5% work in specialist cancer centres and 81.6% counsel men with PCa at least weekly.Only 19.3% reported using any survival prediction tool in their current routine practice.Clinician estimates of 15-year prostate cancer mortality (PCM) exceeded PREDICT Prostate estimates in 92% of the case vignettes; clinicians estimated 1.9-fold greater disease lethality than PREDICT.Clinician perceptions of overall survival benefit from radical treatment at 15 years were over-optimistic in every vignette, with mean clinician estimates 5.4-fold greater than PREDICT.Concomitantly viewing data from PREDICT Prostate led to reductions in likelihood of recommending radical treatment in 9/12 (75%) vignettes, with reductions most evident in intermediate-risk cases.For example, in a fit 75-year old man with PSA 5.1, Gleason 3þ4 PCa in 2/12 biopsy cores: likelihood of recommending treatment dropped from 32.5% to 19.1% when PREDICT estimates were also shown (p[0.009).CONCLUSIONS: Our study suggests clinicians consistently overestimate PCM and the survival benefits of radical treatment.PREDICT Prostate can provide individualised and contextualised prognostic information to help standardise therapy recommendations.

A broader range of decisional tools should be investigated. This paper will update the decisional outcome data and assess the features of decisional tool. Literature search strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles that cited Lin et al and Violette et al were searched. Features of decisional tools were analyzed using the International Patient Decision Aid Standards Instrument criteria. The scores of the 31 decisional tools ranged from 6 to 15, which did not correlate proportionally with the positive decisional outcomes. Personal importance appeared to be a significant component. Multidisciplinary clinics are superior in improving decisional outcomes as they promote more at shared decision making. (C) 2017 Elsevier Inc.

Robot-assisted radical prostatectomy to treat localized prostate cancer has increased in popularity, although other options exist, including radiotherapy and active surveillance. The decision about choosing the right treatment has become pertinent for many patients. This literature review aimed to assess the current state-of-the-art regarding decisional aids and the associated decisional outcomes for the purpose of designing a method for both patients and doctors to use to make the best treatment decision for the patient. A literature search was conducted via MEDLINE, Embase, and Web of Science databases using the keywords “prostate” and “cancer” and “impact” and “decisio*” and “treatment.” Articles were included that focused on treatment outcomes, decision-making processes, and the use of decisional aids for localized prostate cancer. Articles that investigated prostate cancer in general or prostate cancer screening were excluded, as were articles that were not written in English. Altogether, 13 articles were finally critically reviewed for this study. Results were conflicting regarding the relations between patient factors, use of decisional aids, and decisional outcomes. There was a large gap in the literature regarding the optimal decision-making process for men with localized prostate cancer. The role of currently available decisional aids is limited to helping patients make the right decisions. There is a need to develop a novel decisional aid in which patient–physician discussion—involving evaluation of a spectrum of patient-, doctor-, and treatment-related factors—is included.

Background Men diagnosed with localised prostate cancer (LPC) wanting curative treatment face a highly preference-sensitive choice between prostatectomy and radiotherapy, which offer similar cure rates but different side effects. This study aims to determine the information, decision-making needs and preferences of men with LPC choosing between robotic prostatectomy and standard external beam or stereotactic radiotherapy. Methods and analysis This study will be conducted at a large public teaching hospital in Australia offering the choice between robotic prostatectomy and radiotherapy from early 2017. Men (20-30) diagnosed with LPC who want curative treatment and meet criteria for either treatment will be invited to participate. In this mixed-methods study, patients will complete semistructured interviews before and after attending a combined clinic in which they consult a urologist and a radiation oncologist regarding treatment and four questionnaires (one before treatment decision-making and three after) assessing demographic and clinical characteristics, involvement in decision-making, decisional conflict, satisfaction and regret. Combined clinic consultations will also be audio-recorded and clinicians will report their perceptions regarding patients' suitability for, openness to and preferences for each treatment. Qualitative data will be transcribed verbatim and thematically analysed and descriptive statistical analyses will explore quantitative decision-making outcomes, with comparison according to treatment choice. Discussion Results from this study will inform how to best support men diagnosed with LPC deciding which curative treatment option best suits their needs and may identify the need for and content required in a decision aid to support these men. Ethics and dissemination All participants will provide written informed consent. Data will be rigorously managed in accordance with national legislation. Results will be disseminated via presentations to both scientific and layperson audiences and publications in peer-reviewed scientific journals.

This is a case report on a patient with an unusual presentation and clinical course of priapism. It further discusses treatment options with reflection on current literatures and guidelines. 48 year old patient presented with a history of more than 50 episodes of priapism, each lasting for five minutes. Patient had history of brain tumor that was resected and had since been in remission. On examination and further biochemistry assessment revealed conflicting clinical findings, making it difficult to ascertain the type of priapism in this case. The patient, however, recovered from the acute attacks of priapism after 24 hours of conservative management and no obvious cause had been identified on post-discharge follow-up. Priapism, despite being rare, is a medical emergency. This case report reflected upon the limitations of treatment guidelines and the lack of level one evidence to support treatment decisions.