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In their letter about access to scrotal ultrasonography (November 2004, JRSM1) Mr Pocock and his colleagues refer to a large number of inappropriate primary care referrals. Like his, our service has noted increasing referrals for scrotal ultrasound and our assumption was that the majority of these arose from primary care. However, our audit of 569 ultrasound scans performed in the 18 month period from 1 April 2000 to 30 September 2001 showed that general practitioners (GPs) accounted for only 129 (22.7%); by far the largest source of requests was urologists (n=282, 49.6%), followed by general surgeons (n=109, 19.2%). Further analysis of the secondary care requests showed that 46.3% were by consultants, 34.7% specialist registrars or staff grades and 19% junior medical staff.
The median wait for scrotal ultrasound was 36 days, leading to a range of 'journey times' from initial GP referral to diagnosis at orchidectomy up to 127 days: in total, 11 patients in this period were diagnosed by this modality with testicular malignancy. To improve this, we identified the most timely and direct route for referrals, nominated a lead uro-oncologist, and instituted a reduction in the number of clinicians who could request scrotal ultrasonography. These scans are now reported the same day and if testicular tumour is suspected on ultrasound, the para-aortic nodes, kidneys and liver are visualized at the same investigation. The most important point may be to account for the relatively low number of patients diagnosed with testicular tumours both in our audit and in the original paper by Allen et al. (June 2004 JRSM2) which looked specifically at two-week-wait referrals, with only 1 positive diagnosis via this route. Reviewing our practice in the past 12 months we find that 15 patients have been diagnosed with testicular tumours (seminoma 10, teratoma 3, non-Hodgkin lymphoma 2) of whom only 7 (47%) came by two-week referral; 3 were by urgent GP referral, 1 by routine GP referral, 2 by direct GP ultrasound request, with 1 each from oncology (for a second testicular tumour) and general surgery. Reassuringly, median time from ultrasound to inguinal orchidectomy was only 13 days (range 2–19).
This is the group of patients for whom one would imagine the two-week-wait-referral mechanism was designed specifically to help. It is of concern, then, that at least half our patients who are found to have testicular tumours are still not being referred through this route. However, by streamlining ultrasonography practices, one can greatly lessen journey times from referral to definitive surgery.