UK study finds vasectomies are even safer than reported

Vasectomies are much less likely to cause complications than expected, according to a new UK study reviewing the outcomes from over 90,000 vasectomies performed over 15 years.

The study, led by researchers from Gloucestershire Hospitals NHS Foundation Trust, is being presented today at the European Association of Urology (EAU) Congress in Milan.

It shows that existing leaflets explaining the potential complications to patients are based on outdated figures.

Around 11,000 vasectomy operations are performed every year in the United Kingdom, the majority in primary care settings by specialist general practitioners.

The Association of Surgeons of Primary Care, led by Dr Gareth James, gathered data from 94,082 vasectomies between 2006 and 2021, mostly through patient questionnaires; one completed on the day of surgery and the second sent to patients four months post-operation.

Over 80% (around 77,000) of patients filled out the initial questionnaire and just under 40% (36,500) of patients completed the second.

Mr Julian Peacock, a Senior Registrar at Gloucestershire Hospitals NHS Foundation Trust who headed the review along with Mr John Henderson, Consultant Urological Surgeon, said: “This large dataset had never been independently analysed, and doing so has enabled us to update the standard complication rates, some of which dated back to the 1980s.”

For example, one of the most significant complications of a vasectomy is chronic scrotal pain, which is quoted as affecting ‘up to 5% of all patients’ in the British Association of Urological Surgeons (BAUS)’ patient information leaflet about vasectomies. Reviewing the more recent data, the team found that the rate was in fact as low as 0.12% of patients.

Mr Peacock says: “The chances of chronic scrotal pain could be very off-putting, especially as it’s a difficult condition to manage. So we hope that this more up-to-date rate gives a better picture of the small chance of this happening.”

The chances of post-operative infection, and of haematoma – when blood forms a clot in the scrotal tissue – were also reviewed. The rates of infection – taken as any case or condition that had been treated with antibiotics – are quoted as 2-10% of patients in the BAUS statistics, but the team found this was closer to 1.3%.

Haematoma rates in patients is quoted at 2-10% in BAUS statistics, but the updated information suggested this could be as low as 1.4%.

Vasectomy failure rates were available for 70,947 patients. The early failure rate – that’s finding motile sperm at 3 months – was very slightly higher than previously quoted, occurring in 360 patients, or 0.5%, vs BAUS’s figure of 0.4%. Late failure – which occurs when the severed ends of the vas deferens join up – occurred in just 10 patients – or 0.014%. vs BAUS figure of 0.05%.

Mr Peacock added: “Vasectomy is a very reliable and safe contraception method. These figures might encourage more men to undergo the procedure, so we hope our research will be incorporated in the guidelines that provide information for pre-vasectomy counselling and leaflets. “

Dr. Marij Dinkelman-Smit, Assistant Professor of Urology at Erasmus University Medical Centre in Rotterdam, Netherlands, and a member of the EAU’s section of Andrological Urology, said: “Although other countries’ standard information may be more up-to-date, nevertheless it is very useful for us as urologists to see large datasets of patient perspectives on this frequent procedure. As specialists, we mainly see the problems that arise from vasectomies, so it’s relevant for us to fill in the complete picture.”

Male or female urologist? Depends how much it hurts, research shows

Urology involves some of the most intimate medical conditions, yet patients don’t necessarily always prefer to be treated by a urologist of their own gender, new research has found.

In some situations, male and female patients would prefer a male urologist but in others – if they have a painful condition, for example – both men and women would choose to be treated by a female doctor.

The study, by researchers from University Hospital Munich, is being presented today at the European Association of Urology (EAU) Congress in Milan.

Based on a survey of over 1000 patients, the team found that around two thirds of patients expressed some preference as to the gender of their urologist.

Lead researcher Dr Alexander Tamalunas, from University Hospital Munich, said: “Previous research – including a survey we ran a few years ago – found that only around a third of patients have a preference as to whether their urologist is male or female. But these results were based on a single question on the subject.

“Our recent study is more nuanced, looking at whether patients attribute different skills to certain genders or what their choice would be depending on their own symptoms or in certain situations. That leads to a much higher number expressing a preference.”

The study analysed questionnaires from 1012 patients visiting the hospital during 2021, around three quarters of whom were male and just under a quarter female. Three patients were non-binary – an insufficient number to allow the researchers to draw statistically significant conclusions as to the preferences of this group.

The cohort included patients of all ages – although the majority were over 60 – and from all educational and economic backgrounds. Patients were being treated for a range of conditions, and were asked about the impact of these on their lives, as well as whether they felt a male or female urologist would understand them better.

Overall, two thirds of patients expressed a preference for a urologist of a particular gender in at least one scenario – double the numbers found in previous research. In general, where patients expressed a preference, it was for a urologist of their own gender. However, there were certain scenarios where that didn’t hold true.

Both male and female patients preferred to see a male urologist when their conditions were either: embarrassing; limited their daily activities; or caused them concern or inconvenience. However, both male and female patients with any condition with painful symptoms were more likely to choose a female urologist.

For both consultations and surgery, around a third of patients expressed a preference for a particular gender. Of these, the split was about 60:40 in favour of a male urologist for consultations, but this changed to 80:20 for operations.

Men were more likely to deem male urologists as having more practical skills than females, whereas women were more likely to think that a female urologist would be more empathetic.

Both men and women said urologists of their own gender would understand their body better and that it would be easier to talk to them about their condition.

Urology remains a male-dominated profession, but this study highlights the need for a more equal mix of male and female clinicians, say the researchers. University Hospital Munich has fairly equal numbers of male and female doctors in their urology department, but that’s not the case in all hospitals, according to Dr Tamalunas.

“Urology involves very sensitive issues, such as erectile disfunction, incontinence and genital infections, and these conditions are highly personal and sometimes embarrassing to patients,” he said.

“Patients will already find it hard to speak openly to urologists about these conditions and this may be exacerbated by cultural sensitivities in some communities. It’s vitally important that any additional barriers which we can control – such as the gender of the consultant – are removed and for that we need to encourage and support more women in the profession.”

According to Dr Carme Mir Maresma, from the EAU Scientific Congress Office, these findings confirm her own experience.

“Patients’ preferences for their urologist tend to depend on their condition,” she said. “I mainly treat patients with cancer, who are often very ill, and they don’t usually care about the gender of who is treating them, so long as they are well qualified. Patients with conditions that are not life-threatening may be more likely to express a preference.

“However, there are probably also cultural factors at play and it would be interesting to see this research replicated in other countries, to understand their influence.

“Urology is becoming more gender balanced, with fairly equal numbers of men and women at lower levels of the profession. Although men still tend to hold the majority of senior positions, I think that this will change over the next ten years.”

Advanced imaging may help in clinical treatment of prostate cancer

An advanced imaging method is showing promise as a way to improve the diagnosis of prostate cancer by giving clinicians a clearer view of suspected tumours during biopsy.

A trial conducted at the University Hospital Bonn, in Germany, has been testing the benefit of a scanning method known as PSMA-PET/CT to help target where to take biopsy samples.

Interim results reveal that when used alongside standard imaging techniques, the additional scans might help clinicians make improved decisions about subsequent courses of treatment.

Compared to the standard scans alone, when PSMA-PET/CT was used clinicians changed how they might treat a patient with clinically significant prostate cancer in 19% of cases.

The technique also helped to detect significantly more clinically significant prostate cancers.

The findings are presented today at the European Association of Urology Annual Congress in Milan.

“The normal standard of care, which is an MRI scan and then a biopsy, is already good at detecting of prostate cancer, but we wanted to see if PSMA-PET/CT could offer additional information to help with treatment plans,” said Dr Philipp Krausewitz, a urologist at University Hospital Bonn who led the study. “It appears to be having an impact in high-risk patients, but we also saw false positives in 6% of patients that meant we needed further investigations. The question we are considering is whether the additional diagnostics are worthwhile.”

The study, known as the DEPROMP trial, has recruited around 200 men to take part since March 2021. The researchers are hoping to have 230 patients enrolled by the end of the trial. The preliminary results used data from 219 men who all underwent MRI, PSMA-PET/CT and biopsy.

Their scans were then randomly looked at by two separate teams of urologists – one was given the results from the MRI, PSMA-PET/CT and biopsy, while the other group were given the results without the PSMA-PET/CT data. The researchers then compared how the two teams would choose to proceed with treatment based on the information they had.

For example, the clinicians might choose to do surgery to remove the cancer or give the patient chemotherapy.

But it is not yet clear how these decisions might ultimately affect patient outcomes as it can take years and even decades for cancer to return if treated correctly.

“We are seeing a change in cancer detection and management plans in these early results, but we have to wait to see if the final results reflect this,” said Dr Krausewitz. “PSMA-PET/CT is not yet available everywhere as it is expensive, so it is important we understand how it can be effectively used.”

With healthcare systems already under financial strain, the technique will need to offer a substantial improvement in diagnostic capability to be cost effective, added Jochen Walz, associate professor of Urology at the Institut Paoli-Calmettes Cancer Centre in Marseille, France, who commented on the research on behalf of the EAU.

He said: “In the meantime, PSMA-PET/CT could be considered a solution for selected challenging diagnostic cases or those where MRI cannot be done.”

Digital rectal examination is not useful to early detect prostate cancer

A common method of detecting prostate cancer may not be accurate enough as a reliable screening tool by itself, scientists have warned.

The digital rectal exam (DRE) is widely used by medical professionals to check the prostate gland with a finger for unusual swelling or lumps in the rectum as an initial check for the signs of prostate cancer in men.

In some countries, such as Germany, it is the sole method used in a national screening programme for the disease.

But new research by scientists of the PROBASE trial coordinated at the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) in Heidelberg, suggests the technique may be missing many cancers in their early stages.

The findings, which are presented today at the European Association of Urology Annual Congress in Milan, could have implications for the early detection of prostate cancer, say the researchers. They are calling for other testing methods to be used in routine screening instead.

“One of the main reasons for screening for prostate cancer is to detect it in patients as early as possible as this can lead to better outcomes from treatment,” said Dr Agne Krilaviciute, a researcher at DKFZ and lead author of the study. “But our study suggests that the DRE is simply not sensitive enough to detect those early stage cancers.”

The PROBASE trial is a multicenter German prostate cancer screening study across four university sites (TU Munich, Hannover, Heidelberg, Düsseldorf) and involves 46,495 men aged 45 years who were enrolled between 2014 and 2019. The men have since been had follow ups to assess their health in the years after the screening. Half of the participants in the trial were offered prostate specific antigen (PSA) blood test immediately at age 45 while the other half were initially offered DRE with delayed PSA screening at age 50.

Ultimately, 6,537 men in the delayed screening group underwent DRE and only 57 of these men were referred for a follow-up biopsy due to suspicious findings. Only three were found to have cancer.

When compared to the detection rate using other methods, such as a PSA test, the rate of detection using DRE was substantially lower, says Dr Krilaviciute.

“The DRE was giving a negative result in 99% of cases and even those that were deemed to be suspicious had a low detection rate,” says Dr Krilaviciute. “Results we’ve seen from the PROBASE trial show that PSA testing at the age of 45 detected four times more prostate cancers.”

The researchers believe one of the reasons why the DRE might be failing to detect cancers, particularly in younger men, is because the changes in the tissue in the prostate may be too slight to detect with a finger. In addition, some cancers occur in a part of the prostate that cannot be easily reached by a finger.

“Early stage cancer may not have the size and stiffness to be palpable,” said Professor Peter Albers, a urologist at Düsseldorf University who was the senior author of the study.

“Separate analysis that used MRI scans before biopsies to locate cancers in the prostate showed that about 80% of these are in an area that should be easy to reach with a finger and still cancers were not detectable by DRE.”

The researchers are now calling for widespread use of PSA testing and MRI scans as part of screening programmes instead of DRE.

“If the aim of a screening programme is to pick up cancers as early as possible and the current screening tool isn’t doing that job, then that is a fundamental failure of that approach,” said Professor Albers. “We speculate in our paper that not only is the DRE not useful for detecting cancer, but it may also be one reason why people don’t come to screening visits – the examination probably puts a lot of men off.

“In Germany, for example, the participation rate is less than 20% in the screening programme for men 45 to 50 years. If we were to offer PSA testing instead, more of them might be willing to come.”

Long Covid smell loss linked to changes in the brain

People living with long Covid who suffer from loss of smell show different patterns of activity in certain regions of the brain, a new study led by UCL researchers has found.

The research used MRI scanning to compare the brain activity of people with long Covid who lost their sense of smell, those whose smell had returned to normal after Covid infection, and people who had never tested positive for COVID-19.

Published in eClinicalMedicine, the observational study found that the people with long Covid smell loss had reduced brain activity and impaired communication between two parts of the brain which process important smell information: the orbitofrontal cortex and the pre-frontal cortex. This connection was not impaired in people who had regained their sense of smell after Covid.

The findings suggest smell loss, known as anosmia, caused by long Covid is linked to a reversible change in the brain that stops smells from being processed properly. Because it’s clinically reversible, as shown in some subjects, it may be possible to retrain the brain to recover its sense of smell in people suffering the side effects of long Covid.

Dr Jed Wingrove (UCL Department of Medicine) the lead author of the study, said: “Persistent loss of smell is just one way long Covid is still impacting people’s quality of life – smell is something we take for granted, but it guides us in lots of ways and is closely tied to our overall wellbeing. Our study gives reassurance that, for the majority of people whose sense of smell comes back, there are no permanent changes to brain activity.”

MRI study lead and joint senior author Professor Claudia Wheeler-Kingshott (UCL Queen Square Institute of Neurology), said: “Our findings highlight the impact COVID-19 is having on brain function. They raise the intriguing possibility that olfactory training – that is, retraining the brain to process different scents – could help the brain to recover lost pathways, and help people with long Covid recover their sense of smell.”

Researchers say their findings also suggest that the brains of people with long Covid smell loss might be compensating for this lost sense by boosting connections with other sensory regions: their brains had increased activity between the parts of the brain that process smell and areas that process sight (the visual cortex).

“This tells us that the neurons that would normally process smell are still there, but they’re just working in a different way,” said Dr Wingrove.

Professor Rachel Batterham (UCL Department of Medicine), also joint senior author of the study said: “This is the first study to our knowledge that looks at how brain activity changes in people with long Covid smell loss. It builds on the work we undertook during the first wave of the pandemic, which was one of the first to describe the link between COVID-19 infection with both loss of smell and taste.”

The study was funded by the National Institute for Health and Care Research (NIHR).

Split-second of evolutionary mutation could have led to mammals, says UCL researcher

A newly-published hypothesis suggests a momentary leap in a single species on a single day millions of years ago might ultimately have led to the arrival of mammals – and therefore humans.

Published in the Journal of Cell Science, Professor John Martin (UCL Division of Medicine) thinks a single genetic mutation in an egg-laying animal may have resulted in the first formation of blood platelets, approximately 220 million years ago.

In mammals and humans, platelets are responsible for blood clotting and wound healing, so play a significant role in our defence response. Unlike our other cells, they don’t have nuclei – so are unique to mammals, since other classes of animal such as reptiles and birds have blood clotting cells with nuclei.

Our platelets formed from megakaryocytes that mature in the bone marrow. When these megakaryocytes are released into the blood stream and reach the very high pressure blood vessels the lungs, they ‘burst’ apart, each cell releasing thousands of platelets inside the bloodstream.

The researchers suggest that millions of years ago a mammalian ancestor – possibly an animal related to the duck-billed platypus – underwent the very first formation of platelets, thanks to a sudden genetic mutation in its blood clotting cells that meant normal cell division did not take place.

If so, those much larger cells might then have been forced to burst inside the first animal’s blood stream, releasing their cytoplasmic fragments. These fragments proved to be more efficient at stopping bleeding, so if this mutation was inheritable, it would have given its offspring a major advantage through natural selection. An animal with this mutation could stem bleeding from fighting or wounds much better than its competitors, and so live longer.

Professor Martin, Professor of Cardiovascular Medicine at UCL, says: “Because of the uniqueness of platelets, it is reasonable to suggest that a unique event led to their origin. This was a radical, internal evolution occurring in a single animal, on a single day, 220 million years ago, and was then reinforced by natural selection.”

Professor Martin and his colleague Professor D’Avino (University of Cambridge) then suggest that this mutation ultimately led to the development, over 120 millions of years, to the placenta, allowing the foetus to be retained inside the mother for longer-term development and thus allowing evolution to achieve live birth. The ability to clot wounds is an essential element of live birth by means of a placenta, since the placenta splits from the female’s uterus during the birth process. The female would not survive birth and therefore not be able to suckle her offspring if she was unable to stem the bleeding.

In their paper, Professors Martin and D’Avino propose experiments that would support their hypothesis, including in vitro and in animal models.

“Without this critical mutation, we suggest mammals would never have evolved, and therefore human beings would not be around today”, says Professor Martin. “With this research, we’ve laid down a marker based on the available evidence – and we’re suggesting these experiments that will either support or refute our hypothesis.”

New therapy for bile duct cancer extends patients’ lives

A new personalised cancer treatment can radically improve the outlook for some patients with bile duct cancer, a new study involving UCL researchers has found.

The clinical trial – the European arm of which was led by UCL researchers – found that patients who were otherwise facing end of life care survived for up to two years when treated with the drug futibatinib. The results are published in the New England Journal of Medicine.

The drug targets a particular genetic alteration found in around 14% of bile duct cancers, called FGFR2 fusions. Around 300 patients a year in the UK are diagnosed with bile duct cancer with this genetic alteration.

There are very few treatment options for bile duct cancer and the survival is poor, with patients newly surviving on average for just 12 months. Although the cancer is uncommon, incidence is on the rise globally.

This international trial recruited 103 patients with bile duct cancer who had undergone at least one chemotherapy treatment, but whose cancer had become resistant. The patients’ cancer tumours had been genetically analysed to check that they had an alteration in a particular group of genes, known as fibroblast growth factor receptors (FGFR). The drug, futibatinib, is known as an FGFR-2 inhibitor, as it targets this genetic alteration.

When the patients were treated with futibatinib, the results were striking. The drug was more effective at reducing the size of the tumour, with the cancer shrinking by over 40%, compared to 25% with chemotherapy. The drug also produced modest side effects compared to chemotherapy.

Patients on treatment survived for up to two years, even though they had advanced cancer and had sometimes tried up to five other treatments before entering the trial.

European lead and senior author on the paper, Professor John Bridgewater (UCL Cancer Institute and University College Hospitals NHS Foundation Trust) said: “This is a gamechanger, which turns treatment for this group of patients on its head. Instead of treating them with the blunderbuss that is chemotherapy, which attacks healthy cells alongside the cancer, we can offer a truly personalised treatment that just targets a specific alteration within the cancer”.

“The benefits that patients saw in the trial were remarkable. It’s absolutely essential that patients with bile duct cancer get their cancer tested to find out if they have this abnormality. We can’t afford to miss one of these alterations: the difference they could make to treatment outcomes is dramatic.”

There are currently other FGFR inhibitors already in clinical use, including one called pemigatinib, which has been approved for use in the UK by the National Institute for Care and Health Excellence (NICE). However, existing FGFR inhibitors are known to be susceptible to resistance within the cancer. Laboratory tests have shown this is less likely to be a problem with futibatinib, as it targets the FGFR abnormality in a more specific way, and so is likely to be more effective than existing drugs.

Trials are already underway looking at the possibility of using futibatinib as a first line treatment in place of chemotherapy. Professor Bridgewater said: “The question these trials now need to answer is not whether patients should be getting this treatment, but when.

“Hopefully, this kind of genetically driven treatment will become the new normal for oncology. Personalised treatment has long been a buzz word in cancer, but this trial is the real thing – proving that it can be done and bring huge benefits to specific groups of patients.”

COVID-19 increased the vulnerability of people living with obesity

Adults with obesity surveyed in the study reported that their mental health – which is known to be associated with weight gain – had deteriorated between the end of the UK’s first COVID-19 lockdown in July 2020 and September 2021.

The number who struggled to get access to affordable, nutritious food was also substantially higher among this group during the pandemic than was reported in the general population.

The findings serve as a warning about the potential impact of the rising cost of living on people with the disease, according to the researchers. They call for greater support for people living with obesity, both to help address the ongoing impact on their mental health and food poverty longer-term.

The research, which is published in the Journal of Human Nutrition and Dietetics, involved an online survey of 1,187 adults living with obesity in the UK about their mental health, food insecurity and loneliness.

Nearly half of the participants (47.3%) in the study reported that their mental health had grown worse over that period. Nearly a third (32.6%) said they had sought medical support for their mental health. A third (32.4%) reported experiencing moderately severe to severe depression.

Food insecurity – which was assessed using a questionnaire about food they had bought or eaten during the study period – also worsened for some, with 3.1% saying at times they did not eat for a whole day as they lacked enough money or food. Very low food security was identified in 8.1% – nearly three times higher than the levels seen in the general population before the pandemic.

Dr Adrian Brown (UCL’s Centre for Obesity Research), lead author of the study, said: “Our findings suggest that people living with obesity were disproportionately impacted at a time when mental health and food security was declining for everyone during the pandemic.

“We are now entering another period where we are seeing large numbers of people experiencing food poverty, and in some cases, making a choice between buying food or having the heating on. Our findings indicate that people living with obesity will need greater support.”

Obesity affects 28% of adults in England, 25% in Wales and 29% of adults in Scotland. Through the pandemic, people living with obesity were urged to shield themselves by avoiding close contact with others due to the increased risk posed to them by the virus.

Perhaps as a result, the researchers said, almost two thirds (61.7%) of those taking part in the UCL research said they had felt lonely between March 2020 to September 2021, with 27.4% reporting high loneliness – levels that were higher than those seen in other surveys of the general population.

The study follows earlier research by the same team that looked at the mental health of people with obesity during the first COVID-19 lockdown in the UK between March 2020 and July 2020.

Professor Rachel Batterham (UCL Medicine), senior author in both studies, said: “Adults with obesity are twice as likely to die as the result of a COVID-19 infection in England than those without, but our results show that poorer mental health has been another hidden health concern for this group of people.”

The latest UCL study also revealed that many of those living with obesity (79.6%) took active steps to potentially reduce their risk by making changes to their lifestyles. This included buying healthier food, doing more physical activity and eating a healthier diet.

Those with the lowest levels of food insecurity were most likely to buy and eat healthier food.

Despite this, the researchers raise concerns that the combination of COVID-19, the soaring cost of living and a potential reduction in government support due to a recent review of the UK’s Obesity strategy could have long term health implications for the country.

Professor Batterham said: “Poor mental health and food poverty are among the complex factors that drive weight gain. More emphasis is needed to address these if efforts to address obesity are to be successful.”

Dr Brown added: “Obesity is a complex, relapsing, long-term condition. The traditional view has been that we should ‘eat less and exercise more’. But this doesn’t take into account the biological, genetic, social and psychological determinants which all interact in someone developing higher body weight.”