Damien M. Bolton

Objective: To perform a systematic review and meta-analysis of post-radical cystectomy (RC) mortality and complications in older people to aid decision-making pertinent to RC, as bladder cancer is typically a disease of older people, yet older people are less likely than their younger peers to undergo RC, predominantly due to concerns about morbidity and mortality of surgery. Methods: A systematic search of MEDLINE, Scopus and Ovid Emcare was performed in May 2023 for all studies in the past 20 years that reported mortality and/or complications in the 90-days following RC. All studies reporting mortality or complication outcomes in patient groups aged >75 years were included. Exclusion criteria included partial, or organ-sparing cystectomy, non-English language articles, and <20 patients aged >75 years. Results: A total of 76 studies were included, with data from 58 504 older patients across five continents and 19 countries. Post-RC 90-day mortality was 11% in studies reporting outcomes for patients aged ≥80 years, and 7% in studies of patients aged ≥75 years. The 90-day mortality was higher in patients aged ≥80 years compared to patients aged <80 years (odds ratio [OR] 3.42, 95% confidence interval [CI] 1.62-7.22). Older people were more likely to experience a minor (Clavien-Dindo Grade I-II) postoperative complication than younger patients (OR 1.17, 95% CI 1.01-1.36), whereas there was no difference for major complications (Clavien-Dindo Garde III-IV; OR 1.00, 95% CI 0.63-1.60). A higher co-morbid status was more strongly correlated with 90-day mortality in older patients than in younger patients. Conclusions: Older patients face higher postoperative mortality following RC than younger patients. Postoperative outcomes should be weighed against the high risk of cancer-specific death if no curative treatment is offered. Older people must be monitored closely postoperatively to try and prevent death as a result of escalation from minor and major complications.

Objective: To assess the current uses of blockchain technology in surgery and explore potential applications in urology. Methods: A systematic literature review and critical appraisal was performed. The PubMed database was searched for all relevant papers published in English, between 2003 and 2023, on blockchain and surgery, and urology. Results: Our search yielded 59 results (35 eligible studies) for blockchain and surgery, and only six for urology. Current application of blockchain is limited in surgery and sparse in urology. The two main uses are in secured decentralised dataset across multi-national research centres, and personal health records (patient wallet) in parts of Europe. Conclusions: Blockchain is a highly secure technology. Particularly data decentralisation and immutability (once data entered and stored becomes permanently irreversible). Blockchain has the potential to revolutionise digital surgery and urology, especially in the era of artificial intelligence. Our proposed utilisations for blockchain in urology include: decentralised two-level secured operative consent, ureteric stent tracing, supply chain of bacille Calmette-Guérin, improving electronic medical records and large-scale research, optimising surgery and complication reporting and intraoperative documentation, and universal management of low-risk prostate cancer. Widespread awareness and gradual integration of the technology is required within the healthcare system and to the public.

Objective: To analyse whether the percentage of free to total prostate-specific antigen (%fPSA) is a prognostic biomarker in metastatic castration-resistant prostate cancer (mCRPC), as novel studies suggest an elevated %fPSA is associated with adverse oncological outcomes for men with biochemical recurrence of prostate cancer. Methods: A biobank prospectively collated at mCRPC diagnosis was analysed for %fPSA. Clinicopathological characteristics, systemic therapies and survival outcomes were recorded. Patients were stratified by a %fPSA cut-off of 15%. Cox proportional hazard models evaluated whether %fPSA was associated with overall survival (OS) and cancer-specific survival (CSS) across the cohort and by treatment. Results: A total of 254 patients analysed with newly diagnosed mCRPC: 161 (63%) men having a %fPSA ≥15%. The median follow-up was 25.6 months. The median cohort OS and CSS was 39.6 and 43.8 months, respectively. Patients with a %fPSA ≥15% had lower median PSA level (31.30 vs 50.80 ng/mL; P = 0.007) and otherwise comparable clinicopathological and treatment profiles to men with a %fPSA <15%. Adjusting for PSA and on multivariable analysis, a %fPSA ≥15% was associated with shorter OS (multivariable hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.02-2.40; P = 0.039). Among men treated with docetaxel, a %fPSA ≥15% was associated with worse OS (HR 1.84, 95% CI 1.03-3.26; P = 0.038) and CSS. Conversely, %fPSA was not associated with outcomes for men receiving androgen receptor pathway inhibitors (abiraterone acetate or enzalutamide). Conclusions: An elevated %fPSA appears to be an adverse prognostic biomarker. Findings are consistent with biochemical recurrence studies, suggesting a biological basis. Validation and mechanistic studies are warranted.

Objective: To summarise the impact of the coronavirus disease 2019 (COVID-19) pandemic on urological practice globally with a focus on Australian initiatives, as the pandemic resulted in radical changes in healthcare infrastructure and policies. Methods: We conducted a literature review of the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE) and Web of Science medical databases. The key terms used to conduct our search algorithm comprised of 'COVID', 'wait list or wait time or delay', 'urology', 'surgery' and 'outcomes', and generated 231 articles. Abstracts were reviewed for relevance and 40 studies selected for full-text review. Society position statements and government level press release statements were identified through citation tracking and additionally included. Conclusions: The halt on elective surgical services during the pandemic was deemed necessary to curb infection rates and conserve healthcare resources. However, it resulted in extended wait times and large surgical backlogs with major downstream effects. Australia fared favourably with regards to infection rates compared to international populations consequent upon strict border control, vaccine mandates, and stringent lockdowns. However, similar trends were noted in both oncological and non-oncological urology service reduction, resulting in significant concerns regarding the long-term sequelae of delayed surgery and missed appointments upon patient clinical outcome. Initiatives including collaborative partnerships between public and private hospital sectors, government-funded programmes and adoption of telehealth were successfully established as part of Australia's efforts to stabilise our healthcare system in response to the pandemic. Conclusions: Australia's pandemic efforts have highlighted the escalating imbalance between increasing demand from a growing and ageing population on an already over-burdened system with finite resources. The additional strain of managing post-COVID-19 pandemic fallout in this context provides further challenges for clinicians and healthcare administrators alike. Collaboration by all stakeholders must continue in order to seek innovative solutions to maximise efficiency of healthcare service utilisation, so that quality universal healthcare provision may continue in the future.

Objective: To perform a systematic review and meta-analysis to assess the relationship between intraprostatic maximum standardised uptake value (SUVmax) of the dominant prostatic lesion as measured on preoperative prostate-specific membrane antigen (PSMA) positron emission tomography (PET) with radical prostatectomy International Society of Urological Pathology (ISUP) Grade Group, pathological tumour (pT) staging, and biochemical recurrence (BCR). Methods: Prostate-specific membrane antigen PET may offer non-invasive assessment of histopathological and oncological outcomes before definitive treatment. SUVmax of the dominant lesion has been explored as a prognostic biomarker. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we performed reviews of digital libraries and databases and retrieved studies reporting SUVmax quantified on PSMA PET computed tomography or magnetic resonance imaging and subsequent radical prostatectomy ISUP Grade Group, pT stage, and BCR. Quality assessment was performed using Quality Assessment of Diagnostic Accuracy Studies-2 and Prediction model Risk of Bias Assessment tools. Random effects meta-analysis and meta-regression by ISUP Grade Group and pT2 vs pT3/4 stage was performed. This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023408170). Results: After removing duplicates, 23 studies were included for review. Pooled SUVmax (95% confidence interval [CI]) increased monotonically with advancing ISUP Grade Group, with ISUP 1: 5.8 (95% CI 3.9-7.7), through to ISUP 5: 17.3 (95% CI 13.1-21.5). For pT2 disease, pooled SUVmax: 9.7 (95% CI 7.8-11.5) increasing to 13.8 (95% CI 10.9-16.7) for pT3/4 disease. Substantial inconsistency was noted (I2 >50%) for all subgroups. This was not attenuated by restricting analysis only to studies using [68Ga]Ga-PSMA-11. Narrative synthesis of six papers reporting BCR showed increasing SUVmax was associated with reduced time to BCR. Conclusions: Preoperative intraprostatic PSMA SUVmax increases monotonically with higher ISUP Grade Group and pathological tumour stage. Higher SUVmax is associated with reduced BCR-free survival. However, the use of single SUVmax thresholds for clinical decision making is not recommended as variability between studies is high.