Intrarenal pressures during flexible ureteroscopy: an insight into safer endourology.

OBJECTIVES: To assess intrarenal pressures (IRPs) and complication rates after flexible ureteroscopy (fURS), and to assess factors that contribute to raised IRPs and postoperative complications. PATIENTS AND METHODS: After informed consent patients underwent fURS under general anaesthesia. The transducer of a 0.3556 mm (0.014″) pressure guidewire was placed in the renal pelvis for live recording of IRPs. The fURS procedures were performed in a routine manner under antibiotic cover with the aim of dusting the calculus to completion. The operating surgeon was blinded to the live-recorded IRPs. RESULTS: A total of 40 fURS procedures were performed in 37 patients (26 male and 11 female). The mean age was 50.5 years. As a cohort, the mean of average IRPs was 34.8 mmHg and the mean of maximal IRPs was 128.8 mmHg. Pearson's correlation showed a significant inverse correlation between the mean IRP and age (r[38]: -0.391, P = 0.013). Three cases experienced postoperative deviations from uncomplicated recovery, with two being hypotensive and one case being both hypotensive and hypoxic. Three cases returned to the emergency department within 30 days of surgery, with two cases of flank pain and one case of urosepsis with positive urine cultures. The patient presenting with urosepsis had exhibited IRPs exceeding the mean. CONCLUSION: The IRPs changed significantly from normal baseline levels during routine fURS. The mean IRP during fURS correlates with patient age, but not with other factors. The IRP may be related to increased complication rates at fURS. Understanding factors that influence IRP will allow urologists to better manage this intraoperatively.

Mechanism of urosepsis: relationship between intrarenal pressures and pyelovenous backflow.

To document the histological changes observed in renal units subjected to elevated intrarenal pressures (IRPs) and postulate the possible mechanisms of infectious complications after ureteroscopy. MATERIALS AND METHODS: Ex vivo studies were performed on porcine renal models. Each ureter was cannulated with a 10-F dual-lumen ureteric catheter. A pressure-sensing wire was inserted through one lumen and with the sensor positioned in the renal pelvis for IRP measurement. Undiluted India ink stain was irrigated through the second lumen. Each renal unit was subjected to ink irrigation at target IRPs of 5 (control), 30, 60, 90, 120, 150, and 200 mmHg. Three renal units were subjected to each target IRP. After irrigation, each renal unit was processed by a uropathologist. Macroscopically, the amount of renal cortex stained by ink was calculated as a percentage of the total perimeter. Microscopically, presence of ink reflux into collecting ducts or distal convoluted tubules, and pressure-related features, was noted at each IRP. RESULTS: Signs of pressure, as represented by collecting duct dilatation, was first observed at 60 mmHg. Ink staining was consistently observed in the distal convoluted tubules at IRPs ≥60 mmHg, and all renal units above this pressure showed renal cortex involvement. At ≥90 mmHg, ink staining was observed in venous structures. At 200 mmHg, ink staining was observed in supportive tissue, venous tributaries in the sinus fat, peritubular capillaries, and glomerular capillaries. CONCLUSION: Using an ex vivo porcine model, pyelovenous backflow occurred at IRPs of ≥90 mmHg. Pyelotubular backflow occurred when irrigation IRPs were ≥60 mmHg. These findings have implications for the development of complications after flexible intrarenal surgery.

How Do We Learn About Error? A Cross-Sectional Study of Urology Trainees.

OBJECTIVE: This qualitative descriptive study aims to explore trainees' experiences of error disclosure (ED) during their surgical postgraduate training and the factors influencing the intention-behavior gap for ED. DESIGN: This study employs an interpretivist methodology and a qualitative descriptive research strategy. Data were collected using focus group interviews. Data coding was performed by the principal investigator using Braun and Clarke's reflexive thematic analysis. Themes were developed from the data in a deductive manner. Analysis was carried out using NVivo 12.6.1. SETTING: All participants were at various stages of an 8-year specialist program under the auspices of the Royal College of Surgeons in Ireland. The training program involves clinical work in a teaching hospital under the supervision of senior doctors in their specialist field. Trainees attend mandatory communication skills training days throughout the program. PARTICIPANTS: Study participants were recruited using purposive sampling from a sampling frame of 25 urology trainees on a national training scheme. Eleven trainees participated in the study. RESULTS: Participants' stage of training ranged from first to final year. Seven key themes emerged from the data relating to the trainees' experiences of error disclosure and the intention-behavior gap for ED. These themes include observed positive and negative practice in the workplace, impact of stage of training, importance of interpersonal interactions, perceived blame/responsibility for multifactorial error or recognized complication, lack of formal training in ED, cultural aspects of the training environment and medicolegal issues around ED. CONCLUSIONS: While trainees recognize the importance of ED, personal psychological factors, negative environmental culture, and medicolegal concerns are significant barriers to the practice of ED. A training environment that focuses on role-modelling and experiential learning with adequate time for reflection and debriefing is paramount. Areas for further research include broadening the scope of this study of ED across different medical and surgical subspecialties.

Strategies to maximise patient comfort during extracorporeal shockwave lithotripsy - A randomised controlled trial.

BACKGROUND/PURPOSE OF STUDY: We aim to assess if distraction techniques improve patient comfort tolerability of SWL. METHODS: We carried out a prospective randomised controlled trial of SWL-naïve patients attending for treatment. Patients were randomised into three groups and offered oral analgesia as standard of care. Group 1 (n = 19) received stress balls to squeeze during treatment. Group 2 (n = 19) listened to music during treatment. Group 3 (n = 17) received standard of care only. All patients completed a validated health anxiety inventory score prior to treatment. All patients completed a validated pain questionnaire and visual analogue scale (VAS) after treatment. Primary outcomes were completion of SWL treatment and pain score results. RESULTS: 55 patients attending for SWL were randomised. There was no difference in stone size or position, presence of a stent, height or weight between the groups. VAS scores were lower in controls compared to Group 1 (1.93 vs 3.69, p = 0.08). On subgroup analysis of non-anxious patients, pain questionnaire scores were lower in controls compared to Group 1 (2.58 vs 4.77, p = 0.06). VAS scores were lower in patients who received optional analgesia alone than in patients who received stress balls alone (1.92 vs 4.07, p = 0.05). Across all subgroups, pain scores were lower in the control group compared to the distraction groups, but did not achieve significance. CONCLUSIONS: In conclusion, distraction techniques should not replace standard of care for analgesia during SWL. This study was registered with clinicaltrials.gov (identifier NCT03379922).

The transobturator suburethral sling: a safe and effective option for all degrees of post prostatectomy urinary incontinence.

INTRODUCTION: Male stress urinary incontinence (SUI) after radical prostatectomy (RP) is common. The surgical standard of care traditionally has been placement of an artificial urinary sphincter (AUS) but since its introduction the transobturator male sling has been shown to have particular unique advantages. Our aim was to assess outcomes of a consecutive series of suburethral sling insertions in men presenting with all degrees of post RP SUI. MATERIALS AND METHODS: A consecutive cohort of men undergoing AdVance sling insertion following RP were studied. Parameters assessed included pre and postoperative urinary function, 24 hour pad use, quality of life (QoL) outcomes, complications and further treatments. Degree of incontinence was categorized as mild (1-2), moderate (3-5) or severe (≥ 6) depending on daily pad use. Patients were reviewed at 1, 4 and 6 months. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess symptom severity and QoL outcomes. RESULTS: Seventy-seven patients were included, mean age 68 and mean time to sling post RP 34 (8-113) months. Preoperative degree of incontinence: mild 22%, moderate 58%, severe 20%. Fourteen percent had undergone post RP radiation therapy (RT). In total 73% experienced complete resolution of symptoms post sling, 12% significant improvement, 15% no reduction in pad use. Sixty percent with severe incontinence were classified as cured (no pad or 1 dry pad for security reasons). When patients with preoperative RT were excluded, cure rate rose to 82%. On follow up survey at 30 months (mean), the ICIQ-SF score decreased from baseline 17.7 (9-21.0) to 8.0 (0-20) (p < 0.0001), CI 95% (8-12). CONCLUSIONS: Suburethral slings are effective and safe for all degrees of post RP incontinence, are associated with improved QoL parameters and with appropriate selection and counseling are a viable option for more severe degrees of post RP SUI.

Outcomes from the Introduction of a Combined Urology Outpatient Clinic.

BACKGROUND: A combined urology clinic staffed by four consultants and four non-consultant hospital doctors (NCHDs) was introduced in our institution in October 2015. This clinic is supported by a pre-clinic radiology meeting and a synchronous urology clinical nurse specialist (CNS) clinic with protected uroflow/trial of void slots. Herein, we report on the outcomes of this clinic in comparison with the standard format of urology outpatient review. METHODS: We carried out a retrospective review of clinic attendances from May to July 2016. We recorded the number of new and return attendances, which team members had reviewed the patient and patient outcomes. We also calculated the waiting times for new patients to be reviewed in the outpatient clinic. RESULTS: The combined urology clinic reviewed an average of 12 new and 46 return patients per clinic. The standard urology clinic reviewed an average of 8 new and 23 return patients per clinic. 54% of patients were seen by a consultant in the combined urology clinic, and 20% of patients were seen by a consultant in the standard urology clinic. The rate of patient discharge for new patients was 14.8% in the combined clinic compared to 5.9% in the standard clinic. Overall patient outcomes are outlined in the table. The waiting time for review of new patients in the combined clinic was reduced by 39% from 144 days to 89 days over a one-year period. CONCLUSIONS: The introduction of a combined urology outpatient clinic with the support of pre-clinic radiology meeting and synchronous urology CNS clinic facilitates patient discharge.

Neoadjuvant Platinum-Based Chemotherapy is an Independent Predictor for Preoperative Thromboembolic Events in Bladder Cancer Patients Undergoing Radical Cystectomy.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) confers a significant survival benefit in patients with muscle invasive bladder cancer. Platinum-based chemotherapy increases the risk of thromboembolic events (TEE). We determined the effect of cisplatin-based NAC on the incidence of preoperative TEEs in radical cystectomy patients. MATERIALS AND METHODS: A retrospective matched case-control study was performed on 55 patients undergoing radical cystectomy for muscle invasive bladder cancer. Group 1 (n = 20) included patients that received NAC prior to radical cystectomy and Group 2 (n = 35) included patients that underwent radical cystectomy without NAC. Logistic regression analyses tested potential predictors for TEEs in both groups (age, American Society of Anesthesiologists grade, use of NAC, histological subtype, pathological stage). RESULTS: In total, 6 patients of 55 developed a TEE. Five patients of 20 (25%) treated with NAC prior to radical cystectomy developed TEEs, while 1 of 35 (2.9%) treated with radical cystectomy alone developed a TEE. On univariate and multivariate regression analysis, NAC prior to radical cystectomy was an independent predictor for TEE prior to radical cystectomy (p = 0.033 and p = 0.043, respectively). The effect of perioperative anticoagulation on operative blood loss and postoperative hemoglobin level was not statistically significant between both groups (p = 0.22 and p = 0.08, respectively). CONCLUSION: Neoadjuvant cisplatin-based chemotherapy is a significant predictor for preoperative TEE in patients undergoing radical cystectomy.

Simultaneous pancreas and kidney transplantation: Incidence and risk factors for amputation after 10-year follow-up.

INTRODUCTION: The incidence of amputation after simultaneous pancreas and kidney (SPK) transplantation ranges from 9.5% to 23% after 5 years of follow-up. The objective of this study was to investigate the incidence and risk factors for amputation in SPK transplant patients compared to kidney transplantation alone (KTA) after a minimum follow-up of 10 years. METHODS: An analysis was performed on a prospectively maintained database of 81 SPK transplants and 43 KTA consecutively performed in one center for insulin-dependent diabetes mellitus between December 1992 and January 2006. Primary outcome variables were incidence of amputation per patient, total number of amputations, and type of amputation performed. Data are presented as a mean ± standard deviation. RESULTS: Seven patients (9%) in the SPK cohort and one patient (2%) in the KTA cohort underwent amputation (P<.001). One amputee had pancreas allograft failure prior to amputation. Fifteen amputations were performed in total and four patients required ≥2 amputations. The latency period between transplantation and amputation was 133.57±49.43 months in the SPK cohort and 168 months in the KTA group. CONCLUSIONS: The incidence of amputation after SPK transplantation is approximately 9% after 10-year follow-up. Patients are at a significantly greater risk of amputation after SPK transplantation compared to KTA for type 1 diabetes despite insulin independence.

Identification and Cost of Disposable Endourological Devices for Nephrolithiasis: A Cross-Sectional Study Among Urological Trainees.

INTRODUCTION: Knowledge on health economics among urology trainees is not formally assessed. The cost of commonly utilised endourological devices may not be considered by trainees. AIM: The present study was conducted with the aim to assess whether urology trainees were knowledgeable on identification and cost of commonly used disposable devices in the management of nephrolithiasis. MATERIALS AND METHODS: Forty urology trainees in Ireland were invited to complete a visual online questionnaire on the identification of 10 frequently utilised disposable endourological devices. In addition, trainees were requested to estimate the cost of 12 disposable endourological devices. Responses were stratified according to trainee grade and urological subspecialty of interest. Data are presented as a mean ± standard deviation. RESULTS: The response rate was 70% (28/40). Endourology was the subspecialty of interest in 21% (n= 6). No trainee correctly identified all 10 endourological devices and the mean test score was 5.32 ± 2.28. No trainee accurately estimated the cost for all 12 devices assessed. The cost of endourological devices was underestimated by €67.13 ± €60.76 per device. A total of 54% (n=15) of trainees underestimated the total cost of disposable devices used during standard flexible ureterorenoscopy, laser lithotripsy and JJ stent insertion by €303.66 ± €113.83. CONCLUSION: Our findings indicate deficiencies in trainee knowledge on endourological devices and their associated costs. Incorporating a health economics module into postgraduate urology training may familiarise trainees with healthcare expenditure within their departments.

Lithium-induced Nephrotoxicity: A Case Report of Renal Cystic Disease Presenting as a Mass Lesion.

Lithium is an effective therapeutic agent used in the management of bipolar disorder. However, lithium is also associated with several side effects, including renal toxicity. We present a case of a symptomatic cystic mass lesion in the kidney of a patient who had a history of lithium therapy for the management of bipolar disorder.