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Menand JA, Sandhu R, Israel Y, Reford E, Zafar A, Singh P, Cavaliere K, Saleh J, Smith MS, Jodorkovsky D, Luo Y. Digital Rectal Exams Are Infrequently Performed Prior to Anorectal Manometry. Dig Dis Sci 2024; 69:728-731. [PMID: 38170338 DOI: 10.1007/s10620-023-08243-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/10/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Digital rectal examination should be performed prior to anorectal manometry; however, real-world data is lacking. AIMS Characterize real world rates of digital rectal and their sensitivity for detecting dyssynergia compared to anorectal manometry and balloon expulsion test. METHODS A retrospective single-center study was conducted to examine all patients who underwent anorectal manometry for chronic constipation between 2021 and 2022 at one tertiary center with motility expertise. Primary outcomes consisted of the rate of digital rectal exam prior to anorectal manometry; and secondary outcomes included the sensitivity of digital rectal exam for dyssynergic defecation. RESULTS Only 42.3% of 142 patients had digital rectal examinations prior to anorectal manometry. Overall sensitivity for detecting dyssynergic defecation was 46.4%, but significantly higher for gastroenterology providers (p = .004), and highest for gastroenterology attendings (82.6%). CONCLUSIONS Digital rectal examination is infrequently performed when indicated for chronic constipation. Sensitivity for detecting dyssynergic defecation may be impacted by discipline and level of training.
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Affiliation(s)
- Joseph A Menand
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West Hospitals, New York, NY, 10019, USA.
| | - Robinderpal Sandhu
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West Hospitals, New York, NY, 10019, USA
| | - Yonatan Israel
- Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Emma Reford
- Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Ahmun Zafar
- Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West Hospitals, New York, NY, 10019, USA
| | - Priyanka Singh
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Kimberly Cavaliere
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Jean Saleh
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Michael S Smith
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Daniela Jodorkovsky
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
| | - Yuying Luo
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for GI Physiology and Motility, New York, NY, 10019, USA
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Porcaro AB, Gallina S, Bianchi A, Tafuri A, Serafin E, Panunzio A, Mazzucato G, Orlando R, Ditonno F, Ornaghi PI, Rizzetto R, Cerrato C, De Marco V, Brunelli M, Siracusano S, Cerruto MA, Antonelli A. Prognostic impact of palpable prostate tumors on disease progression after robot-assisted radical prostatectomy: a single-center experience. J Robot Surg 2023; 17:2471-2477. [PMID: 37486540 PMCID: PMC10492703 DOI: 10.1007/s11701-023-01669-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/04/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE This study aimed to evaluate the impact of palpable prostate tumors on digital rectal exam (DRE) on the disease progression of prostate cancer (PCa) treated with RARP surgery in a tertiary referral center. MATERIALS AND METHODS Overall, 901 patients were evaluated in a period ranging from January 2013 to October 2020. In the surgical specimen, unfavorable pathology included ISUP grade group ≥3, seminal vesicle invasion (SVI), and pelvic lymph node invasion (PLNI). Disease progression was defined as the occurrence of biochemical recurrence and/or local recurrence and/or distant metastases; its association with the primary endpoint was evaluated by Cox's proportional model. RESULTS Palpable prostate tumors were detected in 359 (39.8%) patients. The overall median (IQR) follow-up was 40 months (17-59). PCa progressed in 159 cases (17.6%). Nodularity or induration of the prostate at DRE was significantly associated with features of unfavorable pathology, increased risk of PCa progression (hazard ratio, HR = 1.902; 95% CI: 1.389-2.605; p < 0.0001) and, on multivariable analysis, was an independent prognostic factor for disease progression after adjusting for clinical and pathological variables. CONCLUSIONS Prostate tumors presenting with an abnormal DRE finding have an independent adverse outcome for disease progression after PCa surgery. They provide also independent prognostic information, as they may be more aggressive than impalpable PCa.
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Affiliation(s)
- Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Sebastian Gallina
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | | | - Emanuele Serafin
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | | | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Francesco Ditonno
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Paola Irene Ornaghi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Riccardo Rizzetto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Clara Cerrato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Vincenzo De Marco
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Matteo Brunelli
- Department of Pathology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Salvatore Siracusano
- Department of Life, Health and Environmental Science, University of L’Aquila, L’Aquila, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani 1, 37126 Verona, Italy
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Beeton G, Alter N, Zagales R, Wajeeh H, Elkbuli A. The benefits and clinical application of the digital rectal exam in trauma populations: Towards enhancing patient safety and quality outcomes. Am J Emerg Med 2023; 63:132-137. [PMID: 36375377 DOI: 10.1016/j.ajem.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/19/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Current literature contains an extensive number of analyses on the diagnostic value and utilization of the direct rectal exam in trauma patients. Presently, ATLS recommends the application of the digital rectal exam in trauma patients following a primary assessment of traumatic injuries. We aim to assess the validity and diagnostic value of the digital rectal exam in trauma populations. METHODS PubMed, Google Scholar, EMBASE, ProQuest, and CINAHL databases were searched for studies from the date of database conception to August 6th, 2022. Studies that assessed the validity of the digital rectal exam performed in the emergency department or trauma bay, in both adult and pediatric trauma patients were included. Study outcomes and measurements of validity were summarized and compared. RESULTS A total of 9 studies met inclusion criteria for both adult and pediatric trauma populations. The sensitivity of the digital rectal exam in detecting both spinal cord and urethral injuries in adult trauma populations ranged from 0 to 50%, while the sensitivity in detecting gastrointestinal injuries ranged from 0% to 51%. When compared to other clinical indicators, the digital rectal exam was consistently worse at detecting injuries. Within the pediatric trauma populations, the digital rectal exam resulted in high false negative rates ranging from 66% to 100%, failing to detect all urethral and gastrointestinal injuries and pelvic fractures. CONCLUSION The use of digital rectal exams in trauma patients illustrates limited to no validity and reliability in assessing pertinent injuries and does not influence the management of injuries. Trauma societies should consider creating guidelines and algorithms to clarify the use of digital rectal exams in specific situations and injury types.
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Affiliation(s)
- George Beeton
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Noah Alter
- NSU NOVA Southeastern University, Dr. Kiran. C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Ruth Zagales
- Florida International University, Miami, FL, USA
| | - Hassaan Wajeeh
- NSU NOVA Southeastern University, College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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Nzeyimana I, Nyirimodoka A, Ngendahayo E, Bonane A, Muhawenimana E, Umurangwa F, Gasana A, Sibomana AM, Teplitsky S, Rusatira C, Rickard J, Hategekimana T, Rwamasirabo E. Diagnosis of advanced prostate cancer at the community level in Rwanda. Int Urol Nephrol 2021; 53:1977-1985. [PMID: 34191229 DOI: 10.1007/s11255-021-02921-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prostate cancer is the second most common cancer in men and sixth leading cause of mortality. If not recognized early, patients with advanced prostate cancer can experience debilitating complications which can otherwise be prevented by early androgen deprivation therapy. This research intends to define clear diagnostic tools that will guide practitioners in the rural community setting toward early management of advanced prostate cancer. METHODS We conducted a cross-sectional observational study at three referral hospitals in Kigali, Rwanda on patients who presented with clinical suspicion of advanced prostate cancer over a period of 6 months. All patients underwent prostate biopsy as well as metastatic work up (CT or MRI), for those who were eligible. Statistical analysis was done using STATA 14.2. RESULTS 114 patients were included in the study. The median age was 70 years (interquartile range: 65-79 years). In total 14 (12.3%) patients were found to have benign disease, while 100 (87.7%) patients were found to have cancer. Among those who had cancer, 85 (85%) had advanced prostate cancer. 110/114 (96.5%) were symptomatic at presentation. Common presenting symptoms were lower urinary tract symptoms (80.7%), back pain (54.4%), and urinary retention (36.8%). Abnormal digital rectal examination (DRE) was a strong risk factor for both cancer and advanced disease. Prostate cancer was found in 92.2% of those with abnormal DRE compared to 41.7% in those with normal DRE (p = 0.001). Also, cancer was found in 96.1% of those with multinodular prostate on DRE (p = 0.02) and had high odds (OR 14.6; CI 3.41-62.25) of having advanced prostate cancer (p < 0.001). The mean (± SD) PSA was 643.3 ± 1829.8 ng/ml and the median (range) was 100 ng/ml (9.05-10,000 ng/ml) for the whole study population. All patients with prostatic-specific antigen (PSA) of 100 ng/ml or above had advanced prostate cancer. CONCLUSION The results show that there is a significant correlation between clinical findings and advanced prostate cancer. All patients with abnormal DRE and PSA above 100 ng/ml had advanced prostate cancer. Diagnosis of advanced prostate cancer is possible at the community level if PSA testing is utilized and practitioners are well trained.
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Affiliation(s)
- Innocent Nzeyimana
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
- University Teaching Hospital of Butare, Huye, Rwanda.
| | - Alexandre Nyirimodoka
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Rwanda Military Hospital, Kigali, Rwanda
| | | | - Alex Bonane
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | | | | | | | | | - Seth Teplitsky
- Department of Urology, University of Kentucky, Lexington, USA
| | | | | | | | - Emile Rwamasirabo
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- King Faisal Hospital, Kigali, Rwanda
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Ankerst DP, Straubinger J, Selig K, Guerrios L, De Hoedt A, Hernandez J, Liss MA, Leach RJ, Freedland SJ, Kattan MW, Nam R, Haese A, Montorsi F, Boorjian SA, Cooperberg MR, Poyet C, Vertosick E, Vickers AJ. A Contemporary Prostate Biopsy Risk Calculator Based on Multiple Heterogeneous Cohorts. Eur Urol 2018; 74:197-203. [PMID: 29778349 DOI: 10.1016/j.eururo.2018.05.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/03/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Prostate cancer prediction tools provide quantitative guidance for doctor-patient decision-making regarding biopsy. The widely used online Prostate Cancer Prevention Trial Risk Calculator (PCPTRC) utilized data from the 1990s based on six-core biopsies and outdated grading systems. OBJECTIVE We prospectively gathered data from men undergoing prostate biopsy in multiple diverse North American and European institutions participating in the Prostate Biopsy Collaborative Group (PBCG) in order to build a state-of-the-art risk prediction tool. DESIGN, SETTING, AND PARTICIPANTS We obtained data from 15 611 men undergoing 16 369 prostate biopsies during 2006-2017 at eight North American institutions for model-building and three European institutions for validation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We used multinomial logistic regression to estimate the risks of high-grade prostate cancer (Gleason score ≥7) on biopsy based on clinical characteristics, including age, prostate-specific antigen, digital rectal exam, African ancestry, first-degree family history, and prior negative biopsy. We compared the PBCG model to the PCPTRC using internal cross-validation and external validation on the European cohorts. RESULTS AND LIMITATIONS Cross-validation on the North American cohorts (5992 biopsies) yielded the PBCG model area under the receiver operating characteristic curve (AUC) as 75.5% (95% confidence interval: 74.2-76.8), a small improvement over the AUC of 72.3% (70.9-73.7) for the PCPTRC (p<0.0001). However, calibration and clinical net benefit were far superior for the PBCG model. Using a risk threshold of 10%, clinical use of the PBCG model would lead to the equivalent of 25 fewer biopsies per 1000 patients without missing any high-grade cancers. Results were similar on external validation on 10 377 European biopsies. CONCLUSIONS The PBCG model should be used in place of the PCPTRC for prediction of prostate biopsy outcome. PATIENT SUMMARY A contemporary risk tool for outcomes on prostate biopsy based on the routine clinical risk factors is now available for informed decision-making.
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Affiliation(s)
- Donna P Ankerst
- Department of Mathematics, Technical University of Munich, Garching, Munich, Germany; Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
| | - Johanna Straubinger
- Department of Mathematics, Technical University of Munich, Garching, Munich, Germany
| | - Katharina Selig
- Department of Mathematics, Technical University of Munich, Garching, Munich, Germany
| | - Lourdes Guerrios
- Department of Surgery, Urology Section, Veterans Affairs Caribbean Healthcare System, San Juan, Puerto Rico
| | - Amanda De Hoedt
- Section of Urology, Durham Veterans Administration Medical Center, Durham, NC, USA
| | - Javier Hernandez
- Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Michael A Liss
- Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Robin J Leach
- Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Stephen J Freedland
- Section of Urology, Durham Veterans Administration Medical Center, Durham, NC, USA; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Nam
- Division of Urology, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Haese
- Martini-Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, URI, IRCCS Hospital San Raffaele, Milano, Italy; Department of Medicine, Vita-Salute San Raffaele University, Milano, Italy
| | | | - Matthew R Cooperberg
- Departments of Urology and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Cedric Poyet
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Emily Vertosick
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
The digital rectal examination (DRE) is performed in children less often than is indicated. Indications for the pediatric DRE include diarrhea, constipation, fecal incontinence, abdominal pain, gastrointestinal bleeding, and anemia. Less well-recognized indications may include abdominal mass, urinary symptoms, neurologic symptoms, urogenital or gynecologic symptoms, and anemia. Indeed, we believe that it should be considered part of a complete physical examination in children presenting with many different complaints. Physicians avoid this part of the physical examination in both children and adults for a number of reasons: discomfort on the part of the health care provider; belief that no useful information will be provided; lack of adequate training and experience in the performance of the DRE; conviction that planned "orders" or testing can obviate the need for the DRE; worry about "assaulting" a patient, particularly one who is small, young, and subordinate; anticipation that the exam will be refused by patient or parent; and concern regarding the time involved in the exam. The rationale and clinical utility of the DRE will be summarized in this article. In addition, the components of a complete pediatric DRE, along with suggestions for efficiently obtaining the child's consent and cooperation, will be presented.
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Affiliation(s)
- Susan R Orenstein
- University of Pittsburgh School of Medicine, 303 Church Ln, Pittsburgh, PA, 15238-1063, USA.
| | - Arnold Wald
- Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, Centennial Building, 1685 Highland Ave, Madison, WI, 53705-2281, USA.
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Rodríguez-Díez MC, Díez N, Merino I, Velis JM, Tienza A, Robles-García JE. Simulators help improve student confidence to acquire skills in urology. Actas Urol Esp 2014; 38:367-72. [PMID: 24332529 DOI: 10.1016/j.acuro.2013.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/23/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To know the level of confidence of fifth year medical students in order to perform maneuvers in bladder catheterization and rectal examination before and after training with simulators. To be able to assess student satisfaction regarding the use of the simulation as a learning method. MATERIAL AND METHODS The study was conducted in the Simulation Center of the Faculty of Medicine. A total of 173 students who completed a practical workshop on the subject of Urology participated. The students were asked to answer anonymous questionnaires on their level of confidence in performing a bladder catheterization and rectal examination before and after the workshop as well as their satisfaction in using the simulation as a training tool. The workshops were organized using groups of 10 students. A teacher or a resident in that area of expertise supervised each student individually, resolving their doubts and teaching them the proper technique. RESULTS All the evaluations made on the different abilities were significantly higher after training (P<.001). Significant differences were found in the confidence level between men and women before the training regarding male urethral catheterization maneuvers and recognition of normal or pathological prostate, The confidence level was lower in women (P<.05). These differences disappeared after training. The level of overall satisfaction with the workshop was high, going from 4.47 ± 0.9 to a maximum score of 5. CONCLUSIONS Simulation is a training method that helps improve the confidence of the medical student in performing a bladder catheterization and digital rectal examination.
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Affiliation(s)
- M C Rodríguez-Díez
- Unidad de Educación Médica y Centro de Simulación, Facultad de Medicina, Universidad de Navarra, Pamplona, España.
| | - N Díez
- Unidad de Educación Médica y Centro de Simulación, Facultad de Medicina, Universidad de Navarra, Pamplona, España
| | - I Merino
- Departamento de Urología, Clínica Universidad de Navarra, Pamplona, España
| | - J M Velis
- Departamento de Urología, Clínica Universidad de Navarra, Pamplona, España
| | - A Tienza
- Departamento de Urología, Clínica Universidad de Navarra, Pamplona, España
| | - J E Robles-García
- Departamento de Urología, Clínica Universidad de Navarra, Pamplona, España
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