Global Incidence and Risk Factors Associated With Postoperative Urinary Retention Following Elective Inguinal Hernia Repair: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) Study.

Importance: Postoperative urinary retention (POUR) is a well-recognized complication of inguinal hernia repair (IHR). A variable incidence of POUR has previously been reported in this context, and contradictory evidence surrounds potential risk factors. Objective: To ascertain the incidence of, explore risk factors for, and determine the health service outcomes of POUR following elective IHR. Design, Setting, and Participants: The Retention of Urine After Inguinal Hernia Elective Repair (RETAINER I) study, an international, prospective cohort study, recruited participants between March 1 and October 31, 2021. This study was conducted across 209 centers in 32 countries in a consecutive sample of adult patients undergoing elective IHR. Exposure: Open or minimally invasive IHR by any surgical technique, under local, neuraxial regional, or general anesthesia. Main Outcomes and Measures: The primary outcome was the incidence of POUR following elective IHR. Secondary outcomes were perioperative risk factors, management, clinical consequences, and health service outcomes of POUR. A preoperative International Prostate Symptom Score was measured in male patients. Results: In total, 4151 patients (3882 male and 269 female; median [IQR] age, 56 [43-68] years) were studied. Inguinal hernia repair was commenced via an open surgical approach in 82.2% of patients (n = 3414) and minimally invasive surgery in 17.8% (n = 737). The primary form of anesthesia was general in 40.9% of patients (n = 1696), neuraxial regional in 45.8% (n = 1902), and local in 10.7% (n = 446). Postoperative urinary retention occurred in 5.8% of male patients (n = 224), 2.97% of female patients (n = 8), and 9.5% (119 of 1252) of male patients aged 65 years or older. Risk factors for POUR after adjusted analyses included increasing age, anticholinergic medication, history of urinary retention, constipation, out-of-hours surgery, involvement of urinary bladder within the hernia, temporary intraoperative urethral catheterization, and increasing operative duration. Postoperative urinary retention was the primary reason for 27.8% of unplanned day-case surgery admissions (n = 74) and 51.8% of 30-day readmissions (n = 72). Conclusions: The findings of this cohort study suggest that 1 in 17 male patients, 1 in 11 male patients aged 65 years or older, and 1 in 34 female patients may develop POUR following IHR. These findings could inform preoperative patient counseling. In addition, awareness of modifiable risk factors may help to identify patients at increased risk of POUR who may benefit from perioperative risk mitigation strategies.

RETention of urine After INguinal hernia Elective Repair (RETAINER study I and II).

PURPOSE: Post-operative urinary retention (POUR) is a well-recognised complication of inguinal hernia repair (IHR). The magnitude of the problem is unclear, and contradictory evidence surrounds postulated risk factors. POUR risks patient distress, catheter-complications and a financial and logistical burden to services. Separately, in the field of IHR, there has been a lack of research into patients' perceptions of surgical 'success'. Our aim is to perform a two-phase, multi-centre prospective study to:Assess the rate, risk factors and impact related to POUR post IH repair.Develop and validate a patient reported outcome measure (PROM) for inguinal hernia repair. METHODS: RETAINER I: We propose a 24-week prospective study with voluntary international participation in 4 week blocks. All patients undergoing elective IH repair (minimally-invasive/open) will be eligible. Standardised data collection will include patient and perioperative factors. Primary outcome will be development of POUR, defined as the need for insertion of a urinary catheter as determined by the treating clinician. Secondary outcomes will be identification of factors predisposing to POUR and the impact of POUR.RETAINER II: A patient reported outcome measure will be developed using representative patient focus groups for item generation, from which an initial questionnaire will be developed and piloted. Validity, reliability, sensitivity and reproducibility will be assessed using the QQ-10 and standard psychometric methodology. CONCLUSIONS: Using an international multicentre collaborative approach will produce the necessary volume of patients, whilst capturing inter-centre variability, to accurately reflect POUR rates and allow analysis of risk factors. This patient pool will provide an excellent opportunity to develop a PROM using appropriate qualitative methodology. HIGHLIGHTS RETAINER I & II PROTOCOLS: RETAINER (RETention of urine After INguinal hernia Elective Repair) I is a prospective, multicentre, international observational study.RETAINER I aims to explore the incidence of and risk factors for urinary retention following elective inguinal hernia repair.Urinary retention following inguinal hernia repair has a marked impact on patients and creates a significant financial and logistical burden for hospital services.RETAINER II is a prospective, qualitative study, recruiting patients to guide the creation of a patient-reported outcome measure (PROM) for elective inguinal hernia repair.

Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials.

PURPOSE: With the publication of a large randomized-controlled trial (RCT) suggesting that tranexamic acid (TXA) may improve head-injury-related deaths, we aimed to determine the safety and efficacy of TXA in acute traumatic brain injury (TBI). METHODS: In this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, CINHAL, ACPJC, Google Scholar, and unpublished sources from inception until June 24, 2020 for randomized-controlled trials comparing TXA and placebo in adults and adolescents (≥ 15 years of age) with acute TBI. We screened studies and extracted summary estimates independently and in duplicate. We assessed the quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO (CRD42020164232). RESULTS: Nine RCTs enrolled 14,747 patients. Compared to placebo, TXA had no effect on mortality (RR 0.95; 95% CI 0.88-1.02; RD 1.0% reduction; 95% CI 2.5% reduction to 0.4% increase, moderate certainty) or disability assessed by the Disability Rating Scale (MD, - 0.18 points; 95% CI - 0.43 to 0.08; moderate certainty). TXA may reduce hematoma expansion on subsequent imaging (RR 0.77; 95% CI 0.58-1.03, RD 3.6%, 95% CI 6.6% reduction to 0.5% increase, low certainty). Risks of adverse events (all moderate, low, or very low certainty) were similar between placebo and TXA. CONCLUSIONS: In patients with acute TBI, TXA probably has no effect on mortality or disability. TXA may decrease hematoma expansion on subsequent imaging; however, this outcome is likely of less importance to patients. The use of TXA probably does not increase the risk of adverse events.

Admission of patients with acute urinary retention leads to a definitive management decision.

BACKGROUND: Acute urinary retention (AUR) is a common urologic emergency. However, its management is not standardized due to lack of clinical guidelines. AIMS: We retrospectively reviewed the treatment of all male patients admitted to our institution with AUR over 12 months. METHODS: Data was obtained from the HIPE (Hospital Inpatient Enquiry) data system, each patient's electronic discharge summary and from patient medical records. RESULTS: There were 130 AUR admissions during the period. About 74 admissions were due to benign prostatic enlargement (BPE). Of these, 45.9% (n = 34) passed their trial without catheter (TWOC). The remainder (n = 40) failed their TWOC necessitating recatheterization and consideration for transurethral resection of prostate (TURP) or re-TWOC. An indwelling urinary catheter (IDC) was inserted for 27.5% (n = 11) of patients with a failed TWOC secondary to comorbidities. This group had a mean age of 78 years (range 68-96 years). Of those who failed their TWOC, 32.5% (n = 13) had a TURP on index admission. Of the remaining 16 patients with failed TWOC, 75% (n = 12) were discharged with an IDC and readmitted for an elective TURP with a median waiting time of 55 days (range 17-138 days). 18.75% (n = 3) passed a re-TWOC and thus offset the need to have any surgical intervention and 6.25% (n = 1) proceeded to a radical retropubic prostatectomy for biopsy proven prostate adenocarcinoma. CONCLUSION: Admission of patients with acute urinary retention leads to a definitive management decision and reduced prolonged catheterization.

Disease detection at the 48-month exit round of the HPV FOCAL cervical cancer screening trial in women per-protocol eligible for routine screening.

HPV FOCAL is a randomized control trial of cervical cancer screening. The intervention arm received baseline screening for high-risk human papillomavirus (HPV) and the control arm received liquid-based cytology (LBC) at baseline and 24 months. Both arms received 48-month exit HPV and LBC cotesting. Exit results are presented for per-protocol eligible (PPE) screened women. Participants were PPE at exit if they had completed all screening and recommended follow-up and had not been diagnosed with cervical intraepithelial neoplasia Grade 2 or worse (CIN2+) earlier in the trial. Subgroups were identified based upon results at earlier trial screening. There were 9,457 and 9,552 and women aged 25-65 randomized to control and intervention and 7,448 (77.8%) and 8,281 (86.7%), respectively, were PPE and screened. Exit cotest results were similar (p = 0.11) by arm for PPE and the relative rate (RR) of CIN2+ for intervention vs. control was RR = 0.83 (95% CI: 0.56-1.23). The RR for CIN2+ comparing intervention women baseline HPV negative to control women with negative cytology at baseline and at 24 months, was 0.68 (95% CI: 0.43-1.06). PPE women who had a negative or CIN1 colposcopy in earlier rounds had elevated rates (per 1,000) of CIN2+ at exit, control 31 (95% CI: 14-65) and intervention 43 (95% CI: 25-73). Among PPE women HPV negative at exit LBC cotesting identified little CIN2+, Rate = 0.3 (95% CI: 0.1-0.7). This per-protocol analysis found that screening with HPV using a 4-year interval is as safe as LBC with a 2-year screening interval. LBC screening in HPV negative women at exit identified few additional lesions.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections.

PURPOSE: 'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base. METHODS: A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. RESULTS: We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). CONCLUSIONS: Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

A double-blind, randomized, placebo-controlled clinical trial evaluating the safety and efficacy of autologous muscle derived cells in female subjects with stress urinary incontinence.

PURPOSE: The purpose of the study was to assess safety and efficacy of autologous muscle derived cells for urinary sphincter repair (AMDC-USR) in female subjects with predominant stress urinary incontinence. METHODS: A randomized, double-blind, multicenter trial examined intra-sphincteric injection of 150 × 106 AMDC-USR versus placebo in female subjects with stress or stress predominant, mixed urinary incontinence. AMDC-USR products were generated from vastus lateralis needle biopsies. Subjects were randomized 2:1 to receive AMDC-USR or placebo and 1:1 to receive 1 or 2 treatments (6 months after the first). Primary outcome was composite of ≥ 50% reduction in stress incontinence episode frequency (IEF), 24-h or in-office pad weight tests at 12 months. Other outcome data included validated subject-recorded questionnaires. Subjects randomized to placebo could elect to receive open-label AMDC-USR treatment after 12 months. Subject follow-up was up to 2 years. RESULTS: AMDC-USR was safe and well-tolerated with no product-related serious adverse events or discontinuations due to adverse events. Interim analysis revealed an unexpectedly high placebo response rate (90%) using the composite primary outcome which prevented assessment of treatment effect as designed and thus enrollment was halted at 61% of planned subjects. Post hoc analyses suggested that more stringent endpoints lowered placebo response rates and revealed a possible treatment effect. CONCLUSIONS: Although the primary efficacy finding was inconclusive, these results inform future trial design of AMDC-USR to identify clinically meaningful efficacy endpoints based on IEF reduction, understanding of placebo response rate, and refinement of subject selection criteria to more appropriately align with AMDC-USR's proposed mechanism of action.

Effect of Screening With Primary Cervical HPV Testing vs Cytology Testing on High-grade Cervical Intraepithelial Neoplasia at 48 Months: The HPV FOCAL Randomized Clinical Trial.

Importance: There is limited information about the relative effectiveness of cervical cancer screening with primary human papillomavirus (HPV) testing alone compared with cytology in North American populations. Objective: To evaluate histologically confirmed cumulative incident cervical intraepithelial neoplasia (CIN) grade 3 or worse (CIN3+) detected up to and including 48 months by primary HPV testing alone (intervention) or liquid-based cytology (control). Design, Setting, and Participants: Randomized clinical trial conducted in an organized Cervical Cancer Screening Program in Canada. Participants were recruited through 224 collaborating clinicians from January 2008 to May 2012, with follow-up through December 2016. Women aged 25 to 65 years with no history of CIN2+ in the past 5 years, no history of invasive cervical cancer, or no history of hysterectomy; who have not received a Papanicolaou test within the past 12 months; and who were not receiving immunosuppressive therapy were eligible. Interventions: A total of 19 009 women were randomized to the intervention (n = 9552) and control (n = 9457) groups. Women in the intervention group received HPV testing; those whose results were negative returned at 48 months. Women in the control group received liquid-based cytology (LBC) testing; those whose results were negative returned at 24 months for LBC. Women in the control group who were negative at 24 months returned at 48 months. At 48-month exit, both groups received HPV and LBC co-testing. Main Outcomes and Measures: The primary outcome was the cumulative incidence of CIN3+ 48 months following randomization. The cumulative incidence of CIN2+ was a secondary outcome. Results: Among 19 009 women who were randomized (mean age, 45 years [10th-90th percentile, 30-59]), 16 374 (8296 [86.9%] in the intervention group and 8078 [85.4%] in the control group) completed the study. At 48 months, significantly fewer CIN3+ and CIN2+ were detected in the intervention vs control group. The CIN3+ incidence rate was 2.3/1000 (95% CI, 1.5-3.5) in the intervention group and 5.5/1000 (95% CI, 4.2-7.2) in the control group. The CIN3+ risk ratio was 0.42 (95% CI, 0.25-0.69). The CIN2+ incidence rate at 48 months was 5.0/1000 (95% CI, 3.8-6.7) in the intervention group and 10.6/1000 (95% CI, 8.7-12.9) in the control group. The CIN2+ risk ratio was 0.47 (95% CI, 0.34-0.67). Baseline HPV-negative women had a significantly lower cumulative incidence of CIN3+ at 48 months than cytology-negative women (CIN3+ incidence rate, 1.4/1000 [95% CI, 0.8-2.4]; CIN3+ risk ratio, 0.25 [95% CI, 0.13-0.48]). Conclusions and Relevance: Among women undergoing cervical cancer screening, the use of primary HPV testing compared with cytology testing resulted in a significantly lower likelihood of CIN3+ at 48 months. Further research is needed to understand long-term clinical outcomes as well as cost-effectiveness. Trial Registration: isrctn.org Identifier: ISRCTN79347302.

Contrast-enhanced ultrasound of the kidney: a single-institution experience.

BACKGROUND: Focal renal masses are typically evaluated by means of triphasic contrast-enhanced CT or MRI scan but use of iodinated contrast or gadolinium is unsuitable for some patients. Contrast-enhanced ultrasound (CEUS) is an imaging alternative in this scenario but has limited availability in Ireland. AIM: The aim of the study was to retrospectively evaluate experience with selective use of CEUS for non-invasive characterization of focal renal masses in a tertiary referral institution in Ireland, with a particular focus on cystic renal lesions and the influence of CEUS on final Bosniak classification and treatment outcomes. METHODS: All cases of renal CEUS between 2009 and 2017 were identified. Imaging history, patient records, histopathology reports, urology conference notes, clinical follow-up details, details of lesion progression or stability on surveillance, biopsy and/or resection details and pre- and post-CEUS Bosniak scores were recorded. RESULTS: Thirty-one patients underwent renal CEUS (7 solid renal lesions, 21 cystic renal lesions and 3 'indeterminate' renal lesions). After CEUS, the CEUS-modified Bosniak score was upgraded in nine patients and downgraded in two patients. All three lesions upgraded from Bosniak III to IV were renal cell carcinomas. One of two lesions downgraded from Bosniak IV to III was resected (cystic nephroma) and the other showed no progression after 19 months of surveillance. CONCLUSION: CEUS is a valuable alternative to CT in assessing complex cystic or solid renal lesions where iodinated CT contrast or gadolinium is inappropriate. CEUS can also refine the Bosniak category of atypical cystic renal lesions and help facilitate treatment decisions.

Reanimating Patients After Traumatic Cardiac Arrest: A Practical Approach Informed by Best Evidence.

Resuscitation of traumatic cardiac arrest is typically considered futile. Recent evidence suggests that traumatic cardiac arrest is survivable. In this article key principles in managing traumatic cardiac arrest are discussed, including the importance of rapidly seeking prognostic information, such as signs of life and point-of-care ultrasonography evidence of cardiac contractility, to inform the decision to proceed with resuscitative efforts. In addition, a rationale for deprioritizing chest compressions, steps to quickly reverse dysfunctional ventilation, techniques for temporary control of hemorrhage, and the importance of blood resuscitation are discussed. The best available evidence and the authors' collective experience inform this article.

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.

Pulmonary metastasis from renal epithelioid angiomyolipoma in the setting of breast cancer.

A 68-year-old woman presented with visible haematuria. Ultrasonography and triphasic CT revealed a 2.6 cm mass in the lower pole of the left kidney. A biopsy suggested low-grade renal cell carcinoma. Radical nephrectomy was performed and revealed an epithelioid angiomyolipoma. At year 3, the patient developed ductal carcinoma of the right breast and underwent a wide local excision and sentinel lymph node biopsy followed by chemotherapy and radiotherapy. 4 months later, she was noted to have a 1.6 cm nodule in the middle lobe of her right lung. The primary differential diagnosis was a breast cancer metastasis. Biopsy revealed a metastatic renal epithelioid angiomyolipoma. The patient elected to have stereotactic radiotherapy over surgical excision. Renal angiomyolipomata are generally regarded as benign tumours. In the present report, we describe the first case of pulmonary metastasis from renal epithelioid angiomyolipoma in the setting of breast cancer.

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.

Disease detection and resource use in the safety and control arms of the HPV FOCAL cervical cancer screening trial.

BACKGROUND: The HPV FOCAL Trial is a RCT comparing human papilloma virus (HPV) with Liquid Based Cytology (LBC) screening for cervical cancer. Results are presented for the comparison of the Safety and Control arms after two rounds. METHODS: HPV FOCAL included randomisation of women aged 25-65 into the Safety arm, where they were initially screened with HPV and the Control arm, where they received entry screening with LBC, with both arms screened again with LBC at 24 months. RESULTS: There are 6203 (Safety) and 6075 (Control) women included in this analysis. For the Safety vs Control arms, Round 1 screening resulted in increased detection of cervical intraepithelial neoplasia 2 or worse (CIN2+),15.3 vs 10.4 per 1000, RR=1.48 (95%CI=1.08-2.03) and higher colposcopy referral rates, 5.6% vs 3.2%. LBC screening at 24 months resulted in similar colposcopy referral rates, 1.5% vs 1.9%, and decreased CIN2+ detection, 2.0 vs 4.7 per 1000, RR=0.43 (95%CI=0.21-0.88) in the Safety vs Control arms. CIN2+ detection and colposcopy referral rates declined with increasing age in both arms. One round of HPV screening detected similar levels of CIN2+ as two rounds of LBC screening. INTERPRETATION: CIN2+ detection at 2 years was lower in those screened by HPV, indicating an improved 2-year negative predictive value of the HPV test.

Rates of self-reported 'burnout' and causative factors amongst urologists in Ireland and the UK: a comparative cross-sectional study.

OBJECTIVES: To determine the incidence of 'burnout' among UK and Irish urological consultants and non-consultant hospital doctors (NCHDs). The second objective was to identify possible causative factors and to investigate the impact of various vocational stressors that urologists face in their day-to-day work and to establish whether these correlate with burnout. The third objective was to develop a new questionnaire to complement the Maslach Burnout Inventory (MBI), more specific to urologists as distinct from other surgical/medical specialties, and to use this in addition to the MBI to determine if there is a requirement to develop effective preventative measures for stress in the work place, and develop targeted remedial measures when individuals are affected by burnout. SUBJECTS AND METHODS: A joint collaboration was carried out between the Irish Society of Urology (ISU) and the British Association of Urological Surgeons (BAUS). Anonymous voluntary questionnaires were sent to all current registered members of both governing bodies. The questionnaire comprised two parts: the first part encompassed sociodemographic data collection and identifying potential risk factors for burnout, and the second used the MBI to objectively assess for workplace burnout. To evaluate differences in burnout, 2 × 2 contingency tables and Fischer's exact probability tests were used. RESULTS: In all, 575 urologists responded to the online survey out of a total of 1380 invites, yielding a 42% response rate. All respondents were aged <75 years (median age 45 years), with men representing 87.5% of respondents. In all, 75% of respondents worked in England, followed by the Republic of Ireland (9%), Scotland (8%), Northern Ireland (4%), and Wales (3%). In all, 79% of respondents were consultants, with 13% representing training posts, and 40% of respondents held a professorship/clinical lead position. Respondents' countries of origin included England, Scotland, Ireland, India, Wales, Malaysia, Pakistan and Sri Lanka. Overall, the mean emotion exhaustion (EE) score was 23.5, representing a moderate level of EE. The mean depersonalisation (DP) score was 8.2, representing a moderate level of DP. The mean personal achievement (PA) score was 17.1, representing high levels of PA. In all, 86 respondents (15%) reported self-medication with non-prescription drugs or alcohol to combat signs and symptoms of burnout, while 46 (8%) sought professional help for symptoms of burnout. In all, 460 respondents (80%) felt that burnout should be evaluated amongst members of the ISU/BAUS, and 345 (60%) would avail of counselling if provided. CONCLUSIONS: This is the first study to address the issue of burnout across two separate health systems in the UK and Ireland. This study has shown previously undescribed high levels of burnout characterised by EE and DP, with associated significant levels of self-medication amongst a male-predominant cohort. Burnout was attributed to non-surgical administrative/institutional factors, with most respondents reporting support for staff evaluation and the provision of counselling services. This pilot study lends itself to the creation of risk stratification for urologists, and an opportunity to provide educational resources, training/development programmes, and collegial and administrative support pathways.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes.

INTRODUCTION: We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN). METHODS: We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS: The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement. CONCLUSIONS: The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Projected Impact of HPV and LBC Primary Testing on Rates of Referral for Colposcopy in a Canadian Cervical Cancer Screening Program.

OBJECTIVE: To estimate the impact of implementing primary human papilloma virus liquid-based cytology (LBC) screening on four-year rates of referral for colposcopy in the British Columbia screening program. METHODS: We used data on referral for colposcopy from an RCT (HPV FOCAL) comparing HPV testing every four years with LBC testing every two years. We also used data from population screening with conventional cytology among women aged 25 to 69. The predicted effect of adoption of either trial protocol on rates of referral for colposcopy was estimated using trial age-specific result and screening result-specific rates weighted by their screening program distribution. The cumulative age-specific rates of referral for colposcopy over four years were calculated. RESULTS: Use of HPV testing initially increased rates of referral for colposcopy in the trial, but over four years the cumulative rates of referral were similar to those for LBC except in women aged 25 to 29, in whom a substantial excess persisted. Four-year rates of referral for colposcopy declined with age in women screened with HPV testing, LBC, and conventional cytology. Extrapolating the trial results to the distribution in the provincial screening program, implementation of either HPV or LBC throughout the provincial population would approximately double the current rates of referral for colposcopy. CONCLUSION: Compared with LBC screening, primary screening for HPV increased rates of referral for colposcopy only among women aged 25 to 29. In contrast to current practice, referral for colposcopy was largely driven by the trial protocol recommendations for the management of abnormal results and not by which screening test was used.

Objectif : Estimer les effets de la mise en œuvre d'un dépistage primaire du virus du papillome humain par cytologie en milieu liquide (CML) sur les taux d'orientation en colposcopie sur quatre ans, dans le cadre du programme de dépistage de la Colombie-Britannique. Méthodes : Nous avons utilisé les données sur l'orientation en colposcopie issues d'un ECR (HPV FOCAL) comparant le dépistage du VPH tous les quatre ans au dépistage par CML tous les deux ans. Nous avons également utilisé des données issues du dépistage populationnel par cytologie conventionnelle mené auprès des femmes de 25 à 69 ans. Le taux d'orientation en colposcopie en fonction de l'âge et le taux d'orientation en colposcopie en fonction des résultats de dépistage ont été pondérés en fonction de la distribution de leurs programmes de dépistage respectifs, ce qui a permis d'estimer l'effet populationnel prévu de l'adoption de l'un ou l'autre des protocoles d'essai en question sur les taux d'orientation en colposcopie. Les taux cumulatifs (en fonction de l'âge) de l'orientation en colposcopie sur quatre ans ont été calculés. Résultats : Le recours au dépistage du VPH a initialement mené à la hausse des taux d'orientation en colposcopie dans le cadre de l'essai; toutefois, sur quatre ans, les taux cumulatifs d'orientation ont été semblables à ceux de la CML, sauf chez les femmes de 25 à 29 ans (chez lesquelles un excès substantiel a persisté). Les taux d'orientation en colposcopie sur quatre ans ont connu une baisse en fonction de l'âge chez les femmes ayant fait l'objet d'un dépistage du VPH, d'une CML et d'une cytologie conventionnelle. En extrapolant les résultats de l'essai à la distribution qui existe au sein du programme provincial de dépistage, nous avons constaté que la mise en œuvre du dépistage du VPH ou de la CML au sein de la population provinciale mènerait au doublement approximatif des taux actuels d'orientation en colposcopie. Conclusion : Par comparaison avec le dépistage par CML, le dépistage primaire du VPH n'a entraîné la hausse des taux d'orientation en colposcopie que chez les femmes de 25 à 29 ans. Contrairement à la pratique actuelle, l'orientation en colposcopie était largement motivée par les recommandations du protocole d'essai en ce qui concerne la prise en charge des résultats anormaux, et non par le test de dépistage utilisé.

Transrectal Ultrasound Guided Biopsy of the Prostate: Is the Information Accessible, Usable, Reliable and Readable?

BACKGROUND/AIMS: To evaluate the accessibility, usability, reliability and readability of Internet information regarding transrectal ultrasound (TRUS) guided biopsy of the prostate. MATERIALS AND METHODS: The terms "prostate biopsy", "TRUS biopsy" and "transrectal ultrasound guided biopsy of the prostate" were separately entered into the each of the top 5 most accessed Internet search engines. Websites were evaluated for accessibility, usability and reliability using the LIDA tool - a validated tool for the assessment of health related websites. Website readability was assessed using the Flesch Reading Ease Score and the Flesch Kincaid Grade Level. RESULTS: Following the application of exclusion criteria, 82 unique websites were analyzed. There was a significant difference in scores depending on authorship categories (p ≤ 0.001), with health related charity websites scoring highest (mean 122.29 ± 13.98) and non-academic affiliated institution websites scoring lowest (mean 87 ± 19.76). The presence of advertisements on a website was associated with a lower mean overall LIDA tool score (p = 0.024). Only a single website adhered to the National Institutes for Health recommendations on readability. CONCLUSIONS: This study demonstrates variability in the quality of information available to Internet users regarding TRUS biopsies. Collaboration of website design and clinical acumen are necessary to develop appropriate websites for patient benefit.

Renal Trauma: The Rugby Factor.

INTRODUCTION: Renal trauma accounts for 5% of all trauma cases. Rare mechanisms of injuries including sports participation are increasingly common. Rugby-related trauma poses a conundrum for physicians and players due to the absence of clear guidelines and a paucity of evidence. Our series highlights traumatic rugby-related renal injuries in our institution, and emphasize the need for international guidelines on management. METHODS: A retrospective review of all abdominal traumas between January 2006 and April 2013, specifically assessing for renal related trauma that were secondary to rugby injuries was performed. All patients' demographics, computerized tomography results, hematological and biochemical results and subsequent management were recorded. RESULTS: Five male patients presented with rugby-related injuries. Mean age was 21 years old. All patients were hemodynamically stable and managed conservatively in acute setting. One patient was detected to have an unknown pre-existing atrophic kidney that had been subsequently injured, and was booked for an elective nephrectomy an 8-week interval. CONCLUSION: Rugby-related trauma has generated essential attention. This paper serves to highlight this type of injury and the need for defined guidelines on role of imaging and international consensus on timing of return to contact sport, in both professional and amateur settings.