Showing papers by "Rick Popert published in 2003"

Repeating the measurement of prostate-specific antigen in symptomatic men can avoid unnecessary prostatic biopsy

Abstract: OBJECTIVES To report the 2-year clinical and biochemical follow-up of symptomatic men who had a high prostate-specific-antigen (PSA) level, for whom our policy has been to avoid biopsy in those with a normal repeat PSA, as minimizing negative prostate biopsies is an important goal in managing men with a high PSA, where the decision for biopsy based on one high value may be inappropriate. PATIENTS AND METHODS In all, 101 men (median age 72 years, range 47–85) referred to a urology department over 1 year with a PSA level above the age-specific reference range (but < 50 ng/mL) had a repeat PSA measurement. Those with a normal PSA and a normal digital rectal examination (DRE) were not biopsied. Their follow-up included a symptom review, DRE and PSA measurements. RESULTS Of the 101 men, 67% presented with LUTS, 11% with symptoms of urinary infection, 8% with haematuria and 9% for screening. In 35 patients the repeat PSA level was normal; in three of these 35 prostate cancer was diagnosed after biopsy because of an abnormal DRE, three were lost to follow-up and one died from unrelated causes. Thus 28 patients were available for review at 2 years. In 23 (82%) the PSA remained within the normal range. In 66 of the 101 men the repeat PSA was abnormal. Cancer was diagnosed in 28 and the remaining 36 with no cancer were managed by PSA review; 30 were reviewed at 2 years and in half of them the PSA level returned to normal. CONCLUSIONS In symptomatic men referred with a raised PSA level and who have a normal DRE and normal repeat PSA, prostatic biopsy can be safely avoided.

Near misses in bladder cancer - an airline safety approach to urology.

Abstract: INTRODUCTION: Traditionally, surgical audit has identified and highlighted the incidence of adverse events complicating a patient's care. The airline industry has taken this concept a step further back by identifying and studying near misses, i.e. events that have the potential to do harm. We have applied this approach to patients with known or suspected bladder cancer. PATIENTS AND METHODS: A prospective study was performed by two urology firms on all patients with known or suspected bladder cancer over a 3-week period. Patients presented to either a central (hub) hospital, or to an associated (spoke) hospital. Four stages in bladder cancer care were considered: (i) diagnostic or check flexible cystoscopy; (ii) admission to hospital prior to TURBT; (iii) peri-operative period; and (iv) first out-patient consultation. A separate proforma, comprising various aspects of management was used for each of these stages of care. If any one criterion was not met, the episode was recorded as a near miss. Near misses were classified as due to capacity limitations in the system, clerical error, equipment failure, clinical error and patient failure. RESULTS: A total of 115 completed episodes were recorded. A near miss was recorded in 65 (56.5%) of all episodes. Capacity limitations accounted for 54%, clinical error for 23%, clerical error for 16%, patient failure for 5% and equipment failure for 2% of all recorded near misses. Of particular note is that near misses relating to diagnosis were more common at the spoke hospital, delayed referral from GPs accounted for more than 25% of clinical error, diagnosis of 5 new bladder tumours was delayed and availability of upper tract imaging was a problem at all phases of patient management. CONCLUSIONS: Near misses are very common in the management of patients with bladder cancer, and their identification should provide a useful framework for identifying potential areas for improvement in patient care.

A randomised trial of periprostatic local anaesthetic for transrectal biopsy.

Abstract: Increasingly transrectal ultrasound and biopsy is performed for the detection of prostate cancer. We have conducted a randomised trial to evaluate whether the addition of periprostatic local anaesthetic injection reduces the discomfort of the procedure. A total of 64 patients who attended a specialised prostate clinic and were being evaluated for an elevated prostate-specific antigen agreed to participate in the trial and were randomly allocated to two groups. The intervention group received 10 ml of 1% lignocaine in the periprostatic tissue prior to biopsy and the control group underwent a standard biopsy. All patients had a sextant biopsy under ultrasound guidance. After the procedure, they were asked to determine the severity of the pain on a scale of 0–10 and the whether the quality of the pain was mild, moderate or severe. The responses were distributed normally. The groups were compared using Student's t-test. Pain severity showed no significant difference between the two groups (P=0.14). There was a trend towards a statistical difference (P=0.07) on the qualitative pain scale. In conclusion, no significant difference in overall discomfort in men having sextant biopsies was detected between the two groups, suggesting that the administration of local anaesthetic may not be as valuable as early reports have suggested.