Chatbots vs andrologists: Testing 25 clinical cases

OBJECTIVE

AI-derived language models are booming, and their place in medicine is undefined. The aim of our study is to compare responses to andrology clinical cases, between chatbots and andrologists, to assess the reliability of these technologies.

MATERIAL AND METHOD

We analyzed the responses of 32 experts, 18 residents and three chatbots (ChatGPT v3.5, v4 and Bard) to 25 andrology clinical cases. Responses were assessed on a Likert scale ranging from 0 to 2 for each question (0-false response or no response; 1-partially correct response, 2- correct response), on the basis of the latest national or, in the absence of such, international recommendations. We compared the averages obtained for all cases by the different groups.

RESULTS

Experts obtained a higher mean score (m=11/12.4 σ=1.4) than ChatGPT v4 (m=10.7/12.4 σ=2.2, p=0.6475), ChatGPT v3.5 (m=9.5/12.4 σ=2.1, p=0.0062) and Bard (m=7.2/12.4 σ=3.3, p<0.0001). Residents obtained a mean score (m=9.4/12.4 σ=1.7) higher than Bard (m=7.2/12.4 σ=3.3, p=0.0053) but lower than ChatGPT v3.5 (m=9.5/12.4 σ=2.1, p=0.8393) and v4 (m=10.7/12.4 σ=2.2, p=0.0183) and experts (m=11.0/12.4 σ=1.4,p=0.0009). ChatGPT v4 performance (m=10.7 σ=2.2) was better than ChatGPT v3.5 (m=9.5, σ=2.1, p=0.0476) and Bard performance (m=7.2 σ=3.3, p<0.0001).

CONCLUSION

The use of chatbots in medicine could be relevant. More studies are needed to integrate them into clinical practice.

LEVEL OF EVIDENCE: 4

Artificial Intelligence: Ready To Pass the European Board Examinations in Urology?

The role of artificial intelligence (AI) in the medical domain is increasing on an annual basis. AI allows instant access to the latest scientific data in urological surgery, facilitating a level of theoretical knowledge that previously required several years of practice and training. To evaluate the capability of AI to provide robust data in a specialized domain, we submitted the in-service assessment of the European Board of Urology to three different AI tools: ChatGPT 3.5, ChatGPT 4.0, and Bard. The assessment consists of 100 single-answer questions with four multiple-choice options. We compared the responses of 736 participants to the AI responses. The average score for the 736 participants was 67.20. ChatGPT 3.5 scored 59 points, ranking in 570th place. ChatGPT 4.0 scored 80 points, ranking 80th, just on the border of the top 10%. Google Bard scored 68 points, ranking 340th. Our study demonstrates that AI systems have the capability to participate in a urological examination and achieve satisfactory results. However, a critical perspective must be maintained, as current AI systems are not infallible. Finally, the role of AI in the acquisition of knowledge and the dissemination of information remains to be delineated.

Patient summary

We submitted questions from the European Diploma in Urological Surgery to three artificial intelligence (AI) systems. Our findings reveal that AI tools show remarkable performance in assessments of urological surgical knowledge. However, certain limitations were also observed.

Mini-percutaneous nephrolithotomy: Is smaller better for kidney stones in patients with neurogenic bladder?

INTRODUCTION

Patients with neurologic bladder are at an increased risk for urolithiasis, and currently, data on mini-percutaneous nephrolithotomy in this population are limited. Our objective was to compare mini (15F)-percutaneous nephrolithotomy, standard (24F)-PCNL and flexible ureteroscopy in terms of efficacy and safety in treatment of kidney stones in patients with neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

We conducted a retrospective monocentric study in our neuro-urological referral centre. All consecutive patients with NLUTD and a cumulative size of renal calculi greater than 15mm or 10mm in the lower calyx, who had extraction surgery between 2005 and 2020, were included. The primary endpoint was the one-session stone-free rate (SFR) at 3 months on a CT scan. The secondary endpoints were complication (Clavien-Dindo grading system), operative time, blood loss and length of hospital stay.

RESULTS

We performed 76 standard PCNL (sPCNL), 46 flexible ureteroscopy lithotripsy (fURL) and 25 miniaturized PCNL (mPCNL). The one-session SFR was 37.5% for the mPCNL group, 38.2% for the sPCNL group and 37% for the fURL group with no significant difference between the three procedures (P=0.99). Early complications, blood loss and transfusion rates were lower in the mPCNL group than in the sPCNL group (P=0.047) and comparable to fURL group. The final SFRs after a second intervention for mPCNL, sPCNL and fURL were 48%, 61.8% and 63%, respectively (P=0.67).

CONCLUSION

The efficacy of mPCNL in patients with NLUTD was not different from other techniques, but a significantly lower rate of complications than sPCNL was observed.

LEVEL OF PROOF

3.

Management of iatrogenic urethral foreign body after mid-urethral sling A literature review

INTRODUCTION

Urethral mesh perforation is a rare complication of mid-urethral sling resulting in a lack of clear management guidelines. Thus, we aimed to determine management options and their respective outcomes in terms of erosion resolution and continence.

METHODS

A literature review was performed by extracting studies from the PubMed, Cochrane, and Google Scholar from January 1996 to December 1, 2022. Only French and English language studies were included. A total of 227 papers were screened and assessed for eligibility.

RESULTS

Forty-eight studies were included in the final analysis, for a total of 224 patients. Treatment options consisted of conservative, endoscopic, transurethral, and transvaginal approaches. Conservative treatment was associated with a 100% risk of persistence or recurrence of urethral perforation, while the failure rates for endoscopic, transurethral, and transvaginal approaches were 33%, 7.5%, and 7%, respectively. Most patients suffered from stress urinary incontinence after reconstructive management. The most common symptoms at the time of presentation were overactive bladder and pain. The mean time between the onset of symptoms and diagnosis was 10 months. About half of the urethral mesh perforations were diagnosed within the first years after the initial sling insertion.

CONCLUSIONS

Multiple management options for sling penetration of the urethra have been described in the literature. Transvaginal sling resection with consecutive tissue interposition seems to carry the lowest risk of erosion recurrence; however, all treatment options are associated with a high relapse rate for stress urinary incontinence.

[Penile necrosis, a specific complication of prostatic artery embolization]

INTRODUCTION

Endoscopic surgery is the standard treatment for benign prostatic hyperplasia (BPH) refractory to pharmacological treatments. In order to reduce invasiveness and preserve sexual function, prostatic artery embolization (PAE) has been developed. However, the technical difficulties of carrying out this procedure and the results, which have yet to be confirmed, mean that it is not currently recommended. The seriousness of the complications generated should lead to a reflection on the benefit-risk balance. The objective is to report a case of penile ischemia after embolization of the prostatic arteries.

MATERIAL AND METHOD

A severe complication following prostatic artery embolization (PAE) is reported with its clinical and paraclinical evaluation before and after the procedure as well as the therapeutic management.

RESULTS

Penile necrosis following prostatic artery embolization was reported in a 75-year-old patient despite an attempt of deobstruction. Lower urinary tract symptoms worsened postoperatively, associated with glans necrosis and refractory erectile dysfunction.

CONCLUSION

The place of PAE in the therapeutic arsenal of BPH needs to be confirmed. This innovative technique exposes the patient to potentially severe risks such as penile ischemia, not encountered in conventional endoscopic surgical treatment. PAE should not be included in the therapeutic armamentarium for BPH outside of clinical trials.

Evaluation of supportive care needs, sexuality and quality of life in phase 1 trials: a prospective monocentric study

PURPOSE

Patients enrolled in oncology phase 1 trials (ph1) usually have advanced heavily pre-treated cancers with few therapeutic options. Quality of life (QoL) is one of the key cancer-treatment outcome measures, especially in ph1, and sexuality is an important part of Qol but rarely explored. This prospective study aims to assess supportive care needs, QoL and sexuality in ph1.

METHODS

Between September 2020 and June 2021, we prospectively recruited patients enrolled in ph1 at Gustave Roussy in France. Supportive care needs, QoL (EORTC QLQ-C30) and sexuality (female sexual function index for women, male sexual health questionnaire [MSHQ] for men) were assessed at baseline, one, three and 5 months. We performed multivariate analyses to identify associations between clinical characteristics, QoL and quality of sexual life over time.

RESULTS

At baseline, we analyzed 187 patients (45% women (n = 84) and 55% men (n = 103)). Patients expressed the need for consultations in pain management, nutrition, psychology and sexology in 28%, 26%, 19% and 9%, respectively. Lower global QoL was independently associated with Royal Marsden Hospital score (p = 0.012), urogenital location tumor (p = 0.021), elevated CRP levels (p = 0.014) and pain intensity (p = 0.005). Ninety-two percent of women had sexual dysfunction. In men, a lower MSHQ score was independently associated with urogenital location tumor (p = 0.021), ECOG Performance Status (p = 0.006), comorbidity at risk (p = 0.024) and pain intensity (p = 0.004).

CONCLUSIONS

There are significant needs for supportive care in ph1, especially in some subgroups of patients. New models of care should be developed to improve early phase pathways.

Impact of Hospital Volume on the Outcomes of Renal Trauma Management

Background

Some health care systems have set up referral trauma centers to centralize expertise to improve trauma management. There is scant and controversial evidence regarding the impact of provider’s volume on the outcomes of trauma management.

Objective

To evaluate the impact of hospital volume on the outcomes of renal trauma management in a European health care system.

Design, setting, and participants

A retrospective multicenter study, including all patients admitted for renal trauma in 17 French hospitals between 2005 and 2015, was conducted.

Intervention

Nephrectomy, angioembolization, or nonoperative management.

Outcome measurements and statistical analysis

Four quartiles according to the caseload per year: low volume (eight or fewer per year), moderate volume (nine to 13 per year), high volume (14–25/yr), and very high volume (≥26/yr). The primary endpoint was failure of nonoperative management defined as any interventional radiology or surgical procedure needed within the first 30 d after admission.

Results and limitations

Of 1771 patients with renal trauma, 1704 were included. Nonoperative management was more prevalent in the very-high- and low-volume centers (p = 0.02). In a univariate analysis, very high hospital volume was associated with a lower risk of nonoperative management failure than low (odds ratio [OR] = 0.54; p = 0.05) and moderate (OR = 0.48; p = 0.02) hospital volume. There were fewer nephrectomies in the high- and very-high-volume groups (p = 0.003). In a multivariate analysis, very high volume remained associated with a lower risk of nonoperative management failure than low (OR = 0.48; p = 0.04) and moderate (OR = 0.42; p = 0.01) volume. Study limitations include all the shortcomings inherent to its retrospective multicenter design.

Conclusions

In this multicenter study, management of renal trauma varied according to hospital volume. There were lower rates of nephrectomy and failure of nonoperative management in very-high-volume centers. These results raise the question of centralizing the management of renal trauma, which is currently not the case in our health care system.

Patient summary

In this study, management of renal trauma varied according to hospital volume. Very-high-volume centers had lower rates of nephrectomy and failure of nonoperative management.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

[Biotherapies for erectile dysfunction and Peyronie's disease: Where are we now?]

INTRODUCTION

Clinical trials of cell therapy for erectile dysfunction (ED) and Peyronie's disease (PD) were recently conducted after preclinical studies.

AIMS

The aims of this study are to give an update on biotherapy for ED and PD and to describe the regulatory framework for these therapies.

MATERIALS AND METHODS

A literature review was performed through PubMed and Clinical.trials.gov addressing cell therapy for ED and PD and using following keywords "erectile dysfunction", "Peyronie's disease", "stem cell", and "platelet-rich plasma".

RESULTS

Preclinical studies in rodent models have shown the potential benefit of cell therapy for ED after radical prostatectomy or caused by metabolic diseases, and PD. The tissues used to obtain the therapeutic product were bone marrow, adipose tissue and blood (PRP, platelet-rich plasma). Mechanism of action was shown to be temporary and mainly paracrine. Four clinical trials were published concerning ED after radical prostatectomy and in diabetic patients and one for PD. Eleven clinical trials including three randomized trials are currently going on. Preclinical and preliminary clinical results suggested the possibility to improve spontaneous erectile function and response to pharmaceutical treatment in initially non-responder patients. This effect is mediated by an improvement of penile vascularization. A reduction of penile curvature without side effect was noted after injections into the plaque of PD patients. Most of these therapeutic strategies using autologous cells were considered as "Advanced Therapy Medicinal Products" with strict regulatory frameworks imposing heavy constraints, in particular in case of "substantial" modification of the cells. The regulatory framework remains unclear and more permissive for PRP and cell therapy processes with extemporaneous preparation/injection and no "substantial" modifications.

CONCLUSIONS

First results on cell therapy for ED and PD are promising. The regulatory framework can significantly change according to cell preparations and origins leading to various constraints. This regulatory framework is crucial to consider for the choice of the procedure.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of andrological and sexual medicine pathologies during the COVID-19 crisis]

OBJECTIVE

To assist urologists in the management of andrological and sexual medicine pathologies during the COVID-19 crisis.

MATERIAL AND METHOD

Use of the formalized consensus method.

RESULTS

The medical and surgical management of patients in andrology and sexual medicine must be adapted. Consultations should, as far as possible, be carried out by tele-consultation. For operative procedures, the delay between the operative decision and the date of (re)scheduling of the procedure will depend on: (1) the level of criticality of the clinical situation; (2) the type of intervention; (3) the functional and psychological repercussions, including quality of life while waiting for the procedure; (4) the notion of losing the chance of having an optimal outcome; (5) the risk of potential complications from delaying a procedure for too long; and (6) taking into account the patient's risk factors for severe forms of COVID-19. The protection of urologists from COVID-19 should be considered. Each urologist must make the best decision for the patient, taking into account the acceptable time frame and quality of life impact before surgical management, the COVID risk parameters, the technical and anesthetic feasibility and the structural possibility of the health care institution to ensure a specific dedicated pathway during the COVID-19 health crisis.

CONCLUSION

The management of andrological and sexual medicine pathologies must be adapted to the COVID-19 crisis context. Some patients may require surgery, including in emergency. These recommendations are transitional and will end with the COVID-19 crisis.

Observation vs. early drainage for grade IV blunt renal trauma: a multicenter study

INTRODUCTION

The aim of this study was to compare observation and early drainage by ureteral stenting in patients with blunt renal trauma and urinary extravasation.

MATERIALS AND METHODS

A retrospective national multicenter study was performed including all patients admitted for renal trauma at 17 hospitals between 2005 and 2015. Patients presenting with a urinary extravasation on initial imaging were considered for inclusion. Patients were divided in two groups according to the initial approach: observation vs. early drainage by ureteral stent (within 48 h after admission). The primary endpoint was the persistence of urinary extravasation on follow-up imaging.

RESULTS

Out of 1799 patients with renal trauma, 238 were included in the analysis (57 in the early drainage and 181 in the observation group). In the early drainage group, 29 patients had persistent urinary extravasation vs. 77 in the observation group (50.9% vs. 42.5%; p value = 0.27). The rates of secondary upper urinary tract drainage did not differ significantly between the early drainage group (26.4%) and the observation group (16%) (p = 0.14). There were no statistically significant differences between the two groups in terms of secondary nephrectomy (0% vs. 2.8%; p = 0.34), and death from trauma (0% vs. 1.8%; p = 0.99). In multivariate analysis, early drainage remained not statistically associated with persistence of urinary extravasation on follow-up imaging (OR = 1.35; p = 0.36) CONCLUSION: In this multicenter cohort, observation was not different from early drainage in terms of persistent urinary extravasation after grade IV blunt renal trauma. Further randomized controlled prospective trials are needed to confirm these findings.

Laparoscopic transposition of lower-pole crossing vessels: Long-term follow-up of 33 patients at puberty

PURPOSE

Laparoscopic transposition of lower-pole crossing vessels (LPCV) has been described as an effective alternative to dismembered pyeloplasty in selected indications of hydronephrosis, with purely extrinsic vascular PUJ obstruction. We hypothesized that the initial good results of laparoscopic transposition of LPCV in children presenting with pure extrinsic PUJO were sustained at puberty when these children go through statural growth, without inducing significant changes in systemic arterial blood pressure. Hence, we analysed the long-term follow-up of adolescents successfully treated with this technique during childhood, reviewed after they have reached puberty, focusing on the incidence of recurrent symptoms, renal dilatation, and systemic hypertension.

PATIENTS AND METHODS

Early 2015, among a cohort of 70 patients prospectively followed-up since they had undergone laparoscopic transposition of LPCV during childhood (2005-2012), we performed systematic clinical assessment of the 33 adolescent patients (16 years; range 12-22) who had reached puberty age. Assessment focused on clinical examination, arterial blood pressure measurements, and renal ultrasonography (Table).

RESULTS

The median delay since surgery was 67 months (31-113 months). Arterial blood pressure adjusted for age and height was within normal range in all patients. Three patients had occasional episodes of abdominal pain: two of them had normal US (including during pain episodes), one had persistent extra-renal dilated pelvis with no calyceal dilatation. None of them showed obvious clinical characteristics linking the pain to a renal origin. Renal US showed residual SFU grade 2 pelvicalyceal dilatation in 2/33 asymptomatic patients; SFU grade 1 extra-renal pelvis dilatation in 3, and was normal in the remaining. When Doppler analysis was performed, there was no evidence of lower-pole parenchyma perfusion defect.

DISCUSSION

In adolescents successfully treated during childhood with transposition of LPCV, there seemed to be no impact of this procedure on systemic arterial blood pressure in adolescents after puberty, nor any evidence of late recurrence of symptoms or hydronephrosis. The main limitation of the present study relies in its retrospective nature, the limited sample size, and the obvious difficulty in adequate selection of candidate patients to this technique. The present experience however reinforces the hypothesis that a vast majority of children can be definitely cured with transposition of LPCV when they represent the sole aetiology of obstruction.

CONCLUSION

In the long-term follow-up, most adolescents successfully treated during childhood by laparoscopic transposition of LCPV for PUJ extrinsic obstruction remain asymptomatic, with normal arterial blood pressure, and normal renal ultrasound when they reach puberty.

[Mineral-based alkaline waters' prescription in France: Patients are the key point for both nephrologists and urologists]

Alkali therapy is frequently used during chronic kidney disease and nephrolithiasis: nephrologists and urologists are the key operators. Very few is known about the underlying conditions of such a prescription: the aim of this study was to delineate those determinants. We conducted a prospective survey where French nephrologists and urologists were involved. Responders were without gender distinction and principally nephrologists. Prescription frequency was associated with gender (women), specialty (nephrologists), indications and perceived efficiency. Urologists prescribe more often during nephrolithiasis and nephrologists during chronic kidney disease. Urologists were more expert (by scoring on mineral-based alkaline waters compositions knowledge). By multivariate analysis, prescription frequency is associated with gender (women), indications and perceived efficiency by prescribers, which is itself influenced by feedback from patients. These results could have been influenced by a huge representation of nephrologists but foster physicians to go on listening to feedback from patients, due to a lack of clinical trials on the efficiency of mineral-based alkaline waters in such a field. Finally, physicians' education (especially young nephrologists) on mineral-based alkaline waters should be intensified.