Cost-effectiveness of a novel urethral catheter safety device in preventing catheterization injuries in the UK.

AIMS: Intraurethral catheter balloon inflation is a substantial contributor to significant catheter-related urethral injury. A novel safety valve has been designed to prevent these balloon-inflation injuries. The purpose of this evaluation was to assess the cost-effectiveness of urethral catheterisation with the safety valve added to a Foley catheter versus the current standard of care (Foley catheter alone). MATERIALS AND METHODS: The analysis was conducted from the UK public payer perspective on a hypothetical cohort of adults requiring transurethral catheterization. A decision tree was used to capture outcomes in the first 30 days following transurethral catheterization, followed by a Markov model to estimate outcomes over a person's remaining lifetime. Clinical outcomes included catheter balloon injuries [CBIs], associated short-term complications, urethral stricture disease, life years and QALYs. Health-economic outcomes included total costs, incremental cost-effectiveness ratio, net monetary benefit (NMB) and net health benefit. RESULTS: Over a person's lifetime, the safety valve was predicted to reduce CBIs by 0.04 per person and CBI-related short-term complications by 0.03 per person, and nearly halve total costs. The safety valve was dominant, resulting in 0.02 QALYs gained and relative cost savings of £93.19 per person. Probabilistic sensitivity analysis indicated that the safety valve would be cost-saving in 97% of simulations run versus standard of care. CONCLUSIONS: The addition of a novel safety valve aiming to prevent CBIs during transurethral catheterization to current standard of care was estimated to bring both clinical benefits and cost savings.

Outcome of acute epididymo-orchitis: risk factors for testicular loss.

PURPOSE: Acute epididymo-orchitis (AEO) is a common urological condition characterised by pain and swelling of the epididymis which can affect men of any age. The aetiology and to some extent the management of the patient differ between paediatric and young and older adult groups. METHODS: A retrospective analysis was performed at the University Hospital Limerick from 2012 to 2016. Hospital In-Patient Enquiry (HIPE) data were obtained for all patients diagnosed with orchitis, epididymitis, epididymo-orchitis or testicular abscess over this 5-year period. RESULTS: 140 patients were identified, the age range was 0-89, median age 35.6. These were then split into 3 clinical groups, pre-pubertal (Group 1, 0-15-year-olds), sexually active young men (Group 2a, 16-35-year-olds) and men over 35 (Group 2b). Nine patients had an abscess on ultrasound investigation. There was a significant correlation between the presence of an abscess and the need for an orchidectomy (2 patients, P = 0.035). Two patients were reported as having an atrophic testis following AEO and both were in Group 2b. CONCLUSION: Overall, 7/131 (5%) patients had loss or atrophy of a testicle following an episode of AEO. Nineteen patients had further readmissions with AEO (14%).

Mechanical and morphological characterisation of porcine urethras for the assessment of paediatric urinary catheter safety.

Paediatric urinary catheters are often necessary in critical care settings or to address congenital anomalies affecting the urogenital system. Iatrogenic injuries can occur during the placement of such catheters, highlighting the need for a safety device that can function in paediatric settings. Despite successful efforts to develop devices that improve the safety of adult urinary catheters, no such devices are available for use with paediatric catheters. This study investigates the potential for utilising a pressure-controlled safety mechanism to limit the trauma experienced by paediatric patients during inadvertent inflation of a urinary catheter anchoring balloon in the urethra. Firstly, we establish a paediatric model of the human urethra using porcine tissue by characterising the mechanical and morphological properties of porcine tissue at increasing postnatal timepoints (8, 12, 16 and 30 weeks). We identified that porcine urethras harvested from pigs at postnatal week 8 and 12 exhibit morphological properties (diameter and thickness) that are statistically distinct from adult porcine urethras (postnatal week 30). We therefore utilise urethra tissue from postnatal week 8 and 12 pigs as a model to evaluate a pressure-controlled approach to paediatric urinary catheter balloon inflation intended to limit tissue trauma during inadvertent inflation in the urethra. Our results show that limiting catheter system pressure to 150 kPa avoided trauma in all tissue samples. Conversely, all of the tissue samples that underwent traditional uncontrolled urinary catheter inflation experienced complete rupture. The findings of this study pave the way for the development of a safety device for use with paediatric catheters, thereby alleviating the burden of catastrophic trauma and life changing injuries in children due to a preventable iatrogenic urogenital event.

A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries.

OBJECTIVES: To perform a multi-institutional investigation of incidence and outcomes of urethral trauma sustained during attempted catheterization. PATIENTS & METHODS: A prospective, multi-center study was conducted over a designated 3-4 month period, incorporating seven academic hospitals across the UK and Ireland. Cases of urethral trauma arising from attempted catheterization were recorded. Variables included sites of injury, management strategies and short-term clinical outcomes. The catheterization injury rate was calculated based on the estimated total number of catheterizations occurring in each center per month. Anonymised data were collated, evaluated and described. RESULTS: Sixty-six urethral catheterization injuries were identified (7 centers; mean 3.43 months). The mean injury rate was 6.2 ± 3.8 per 1000 catheterizations (3.18-14.42/1000). All injured patients were male, mean age 76.1 ± 13.1 years. Urethral catheterization injuries occurred in multiple hospital/community settings, most commonly Emergency Departments (36%) and medical/surgical wards (30%). Urological intervention was required in 94.7% (54/57), with suprapubic catheterization required in 12.3% (n = 7). More than half of patients (55.56%) were discharged with an urethral catheter, fully or partially attributable to the urethral catheter injury. At least one further healthcare encounter on account of the injury was required for 90% of patients post-discharge. CONCLUSIONS: This is the largest study of its kind and confirms that iatrogenic urethral trauma is a recurring medical error seen universally across institutions, healthcare systems and countries. In addition, urethral catheter injury results in significant patient morbidity with a substantial financial burden to healthcare services. Future innovation to improve the safety of urinary catheterization is warranted.

The recurrent urinary tract infection health and functional impact questionnaire (RUHFI-Q): design and feasibility assessment of a new evaluation scale.

INTRODUCTION: We aim to design a tool to assess the impact of recurrent urinary tract infection (rUTI) on quality of life (QoL) in adult women, given the notable absence of an established instrument for this purpose. MATERIALS AND METHODS: Best practice guidelines in health-related survey design were reviewed. A literature review informed creation of an interview guide. Following ethical approval, 10 female patients (23-38 years) with rUTI were invited to participate in phase 1 of questionnaire design; all agreed. Individual semi-structured interviews were conducted exploring the impact of rUTI on patients' QoL. Interviews were repeated with 5 staff members (3 urology nurses and 2 consultant urologists). Responses were recorded and thematic analysis performed, to inform the design of a new questionnaire. A further 10 patients were recruited to assess feasibility of completion. RESULTS: All participants found available questionnaires unfit for assessment of rUTI-related QoL. Multiple themes emerged as integral to an rUTI questionnaire, including: frequency of UTIs, duration of symptoms, time to full recovery, specific symptoms of UTI, constitutional symptoms, impact on work/education, impact on leisure activities, impact on interpersonal relationships, impact on sexual relationships, psychological aspects and implications of treatment. Data saturation was reached. Based on responses, the Recurrent Urinary tract infection Health and Functional Impact Questionnaire (RUHFI-Q) was drafted, comprising 10 domains and 16 items. CONCLUSIONS: We propose a novel self-administered questionnaire, the RUHFI-Q, as an instrument to standardize evaluation of the QoL impact of rUTI in a population of premenopausal women. Further validation studies are in progress.

Cryopreservation of porcine urethral tissue: Storage at -20°C preserves the mechanical, failure and geometrical properties.

Cryopreservation is required to preserve the native properties of tissue for prolonged periods of time. In this study, we evaluate the impact that 4 different cryopreservation protocols have on porcine urethral tissue, to identify a protocol that best preserves the native properties of the tissue. The cryopreservation protocols include storage in cryoprotective agents at -20 °C and -80 °C with a slow, gradual, and fast reduction in temperature. To evaluate the effects of cryopreservation, the tissue is mechanically characterised in uniaxial tension and the mechanical properties, failure mechanics, and tissue dimensions are compared fresh and following cryopreservation. The mechanical response of the tissue is altered following cryopreservation, yet the elastic modulus from the high stress, linear region of the Cauchy stress - stretch curves is unaffected by the freezing process. To further investigate the change in mechanical response following cryopreservation, the stretch at different tensile stress values was evaluated, which revealed that storage at -20 °C is the only protocol that does not significantly alter the mechanical properties of the tissue compared to the fresh samples. Conversely, the ultimate tensile strength and the stretch at failure were relatively unaffected by the freezing process, regardless of the cryopreservation protocol. However, there were alterations to the tissue dimensions following cryopreservation that were significantly different from the fresh samples for the tissue stored at -80 °C. Therefore, any study intent on preserving the mechanical, failure, and geometric properties of urethral tissue during cryopreservation should do so by freezing samples at -20 °C, as storage at -80 °C is shown here to significantly alter the tissue properties.

Stress Urinary Incontinence and Pelvic Organ Prolapse: Biologic Graft Materials Revisited.

Symptomatic stress urinary incontinence (SUI) and pelvic organ prolapse (POP) refractory to conservative management with pelvic floor muscle training or vaginal pessaries may warrant surgical intervention with different forms of biologic or synthetic material. However, in recent years, several global regulatory agencies have issued health warnings and recalled several mesh products due to an increase in complications such as mesh erosion, infection, chronic pain, and perioperative bleeding. At present, current surgical treatment strategies for SUI and POP are aimed at developing biological graft materials with similar mechanical properties to established synthetic meshes, but with improved tissue integration and minimal host response. This narrative review aims to highlight recent studies related to the development of biomimetic and biologic graft materials as alternatives to traditional synthetic materials for SUI/POP repair in female patients. We also investigate complications and technical limitations associated with synthetic mesh and biological biomaterials in conventional SUI and POP surgery. Our findings demonstrate that newly developed biologic grafts have a lower incidence of adverse events compared to synthetic biomaterials. However there remains a significant disparity between success in preclinical trials and long-term clinical translation. Further characterization on the optimal structural, integrative, and mechanical properties of biological grafts is required before they can be reliably introduced into clinical practice for SUI and POP surgery. Impact statement Our review article aims to outline the clinical history of developments and controversies associated with the use of synthetic mesh materials in the surgical treatment of stress urinary incontinence and pelvic organ prolapse, as well as highlighting recent advancements in the area of biological graft materials and their potential importance in an area that remains an enduring issue for patients and clinicians alike. This article aims to provide a concise summary of previous controversies in the field of urinary incontinence, while evaluating the future of potential biomaterials in this field.

Significance of spermatic cord invasion in radical inguinal orchidectomy: Will a modified subinguinal orchidectomy suffice?

INTRODUCTION AND OBJECTIVES: Radical inguinal orchidectomy with ligation and division of the spermatic cord at the deep inguinal ring is the treatment of choice for testicular mass suspicious of cancer. In the era of organ preserving and minimally invasive surgery, it may be possible to propose a less radical sub-inguinal orchidectomy that may avoid the morbidity associated with opening the inguinal canal. The effect of this approach on oncological margins is not known. The aim of this article was to investigate the presence of spermatic cord involvement after a radical inguinal orchidectomy with a view to test feasibility of a modified sub-inguinal approach for testicular tumour excision. MATERIALS AND METHODS: A retrospective study on all orchidectomies performed for suspected testicular cancer was performed at a single hospital from over an 8-year period from January 2005 to December 2013. Non-cancerous lesions were excluded after histopathological review. All testicular malignancies were included and detailed histopathological review was performed. RESULTS: A total of 121 orchidectomies were performed over the 8-year period. Three patients had spermatic cord involvement. Spermatic cord involvement did not adversely affect the outcome in these patients after a median follow-up of 5 years irrespective of tumour histology. The proximal spermatic cord was not involved in any testicular germ cell tumours on further cord sectioning, the only patient with proximal cord involvement had a B-cell lymphoma. CONCLUSION: We postulate that a sub-inguinal modified orchidectomy may be a less invasive alternative to radical inguinal orchidectomy, with comparable oncological outcomes based on low risk of spermatic cord involvement, which in itself is not a prognostic factor. We require further long-term follow-up studies on patients who have undergone this approach to validate the oncological outcomes and report the possible advantage of lower post-operative complications with this technique.

The Effect of Bladder Filling Rate on the Voiding Behavior of Patients with Overactive Bladder.

PURPOSE: Many self-help guides advise patients that spreading fluid intake throughout the day can reduce overactive bladder symptoms. However, although animal studies suggest a link between a faster filling rate and increased afferent nerve firing, to our knowledge the relationship between the filling rate and bladder sensation has not been examined in humans. The aim of this study was to investigate the effect of bladder volume and the bladder filling rate on the bladder sensation and voiding patterns of patients with overactive bladder. MATERIALS AND METHODS: A control group of 40 female volunteers were recruited by open advertisement. A further 24 female patients with overactive bladder were recruited from the urology outpatient department. Each participant completed the UDI-6 (Urinary Distress Inventory, Short Form), the IIQ-7 (Incontinence Impact Questionnaire, Short Form) and a 3-day sensation related bladder diary. RESULTS: The proportion of urgent voids in the control group increased with increasing voided volume and bladder filling rates (each p ≤0.001). The proportion of urgent voids in patients with overactive bladder also increased with increasing voided volume and bladder filling rates (p = 0.004 and 0.013, respectively). On regression analysis the rate of bladder filling was an independent predictor of urgent voids in patients with overactive bladder but not in the control group. Patients with overactive bladder were less tolerant of higher bladder filling rates, and experienced most grades of bladder sensation at lower voided volumes and filling rates than the control group. CONCLUSIONS: The bladder filling rate appears to influence the intervoiding interval and the sensation associated with each void in patients with overactive bladder. Advising patients to lower the bladder filling rate should help reduce urinary frequency, urgency and urge incontinence.

Direct mechanical characterization of prostate tissue-a systematic review.

BACKGROUND: Direct mechanical characterization of tissue is the application of engineering techniques to biological tissue to ascertain stiffness or elasticity, which can change in response to disease states. A number of papers have been published on the application of these techniques to prostate tissue with a range of results reported. There is a marked variability in the results depending on testing techniques and disease state of the prostate tissue. We aimed to clarify the utility of direct mechanical characterization of prostate tissue in identifying disease states. METHODS: A systematic review of the published literature regarding direct mechanical characterization of prostate tissue was undertaking according to PRISMA guidelines. RESULTS: A variety of testing methods have been used, including compression, indentation, and tensile testing, as well as some indirect testing techniques, such as shear-wave elastography. There is strong evidence of significant stiffness differences between cancerous and non-cancerous prostate tissue, as well as correlations with prostate cancer stage. There is a correlation with increasing prostate stiffness and increasing lower urinary tract symptoms in patients with benign prostate hyperplasia. There is a wide variation in the testing methods and protocols used in the literature making direct comparison between papers difficult. Most studies utilise ex-vivo or cadaveric tissue, while none incorporate in vivo testing. CONCLUSION: Direct mechanical assessment of prostate tissue permits a better understanding of the pathological and physiological changes that are occurring within the tissue. Further work is needed to include prospective and in vivo data to aid medical device design and investigate non-surgical methods of managing prostate disease.

Bladder neck placement of a synthetic polypropylene sling for the treatment of stress urinary incontinence.

INTRODUCTION: Pubo-vaginal sling placed at the bladder neck is the gold standard treatment for stress urinary incontinence (SUI). The synthetic mid-urethral sling (MUS) is now widely used, as morbidity rates with this technique are substantially reduced. This is an initial report on long-term outcomes of a polypropylene sling (PPS) placed in the traditional bladder neck location. METHODS: A retrospective analysis of all patients who underwent PPS insertion at our institution between 2006 and 2014 was conducted. Patient and urodynamic demographics were recorded. Subjective and objective measures of success were determined by postoperative pad usage and validated incontinence questionnaires. RESULTS: A total of 170 patients were followed for a median of four years (range 1-8). The mean age was 51 years (±10). Subjective response was assessed in 57% of patients; the overall subjective cure rate was 85.3% (n=145), subjective improvement rate was 4.1% (n=7), and the subjective failure rate was 10.6% (n=18). The mean Urogenital Distress Inventory (UDI)-6 score was 6.5 (±5.6) out of a maximum score of 24 and the Incontinence Impact Questionnaire (IIQ)-7 score was 5.5 (±6.3) out of a maximum score of 28. There was no significant difference in objective outcome measures in those with an abdominal leak-point pressure (ALPP) < or >60 cmH2O. CONCLUSIONS: Bladder neck placement of a PPS resulted in cure rates of 85% in this series. SUI secondary to intrinsic sphincter deficiency (ISD) and urethral hypermobility were treated with equal success. Bladder neck PPS placement has a role in the treatment of SUI. Our data may well reassure rectus fascia sling (RFS) surgeons who wish to take advantage of faster postoperative recovery using the less invasive PPS placed at the bladder neck.

Patient experience after transperineal template prostate biopsy compared to prior transrectal ultrasound guided prostate biopsy.

INTRODUCTION: Transperineal template prostate biopsy (TTPB) is reported to have higher cancer detection and lower complication rate compared to transrectal ultrasound guided prostate biopsy (TRUSPB).However, there is no report of the same patient's experience with both types of biopsy.To compare the patient reported experience in the same cohort of patients who underwent both TRUSPB and TTPB, using validated questionnaires. MATERIAL AND METHODS: We retrospectively utilised the Patient Reported Outcome Methods (PROM) tool validated for TRUSPB and the International Index of Erectile Function (IIEF-5) questionnaire to collect longitudinal data at follow-up in the same cohort of patients who underwent both TTPB and TRUSPB between January 2015 and February 2016. RESULTS: Out of 44 TTPB performed during the period, 35 patients had undergone both TRUSPB and TTPB. Patient reported pain post biopsy was significantly higher with TRUSPB (86% vs. 61%; p = 0.01). Post-biopsy urinary retention rates were significantly higher in the TTPB group (16.7% vs. 5.7%; p = 0.05, t test). Furthermore, the incidence of patient reported sexual dysfunction rates based on the IIEF-5 was significantly higher in the TTPB group (p = 0.001, t test). CONCLUSIONS: Although overall TTPB was better tolerated in this cohort of patients with lower risk of health care contact, patients reported higher incidence of urinary retention and sexual dysfunction after TTPB compared to TRUSPB. Thus, patients should be adequately informed about potential risks with each biopsy as they may have significant impact on quality of life.

Hospital burden of long-term genitourinary and gastrointestinal toxicity after radical radiotherapy for prostate cancer.

INTRODUCTION: Treatment options for prostate cancer (PCa) include radical radiotherapy (RT) and radical prostatectomy, both of which have comparable oncological outcomes. The aim of this study was to investigate the hospital burden of long-term genitourinary and gastrointestinal toxicity among patients with PCa who were treated with radiotherapy at our institution. METHODS: The radiotherapy department database was used retrospectively to identify all patients who underwent radiotherapy for PCa from January 2006 to January 2008. The patient administration system from each public hospital in the region was interrogated and all patient points of contact were recorded. Minimum follow up was 5 years. Individual patient charts were reviewed and factors that might influence outcomes were documented. RESULTS: We identified 112 patients. The mean age at diagnosis was 66 (44-76) and the median PSA was 12.1 (3.2-38). The mean duration of follow-up was 7.8 yrs. Twenty-three patients (20%) presented to the Emergency Department (ED) with late onset toxicity. Nine patients had more than 2 ED attendances. Twenty-five patients (22%) were investigated for genitourinary toxicity. Forty-seven patients (42%) underwent investigation for gastrointestinal side-effects and 45% of these required argon therapy (21/47). CONCLUSION: We found a significant hospital burden related to the management of gastrointestinal and genitourinary toxicity post radical radiotherapy for prostate cancer. As health care reforms gain momentum, policy makers must take into account the considerable longitudinal health care cost related to radiotherapy. It is also important that patients are counselled carefully in relation to potential long-term side-effects.

Increasing detection of significant prostate cancer in younger men - ten year trends in prostate cancer risk profile in the Mid-West of Ireland.

INTRODUCTION: Although PSA (prostate specific antigen) based screening for prostate cancer (PCa) is controversial, an increasing number of men are undergoing Transrectal Ultrasound Guided prostate biopsy (TRUSPB) through primary care-based PSA testing and referral to hospitals. The aim of our study was to investigate presenting risk profiles of PCa over the last decade in a cohort of men in Ireland and to examine any change in the same over this time period. MATERIAL AND METHODS: The hospital patient administration system was analysed for patients who underwent TRUSPB from January 2005 to December 2015. Clinically significant PCa was defined as Gleason score of 7 or above. RESULTS: Complete data was available on 2391 TRUSPB patients: number of biopsies increased by 53%, median age decreased by 0.9%, median PSA decreased by 6% (p = 0.001, ANOVA) and abnormal DRE increased by 9% (p = 0.001, chi square). Overall positive biopsy was 44% and significant cancer rate was 21%. There was a significant change in trend of detection (p = 0.02) with average annual increase in significant cancer of 3%. The median age of the significant cancer cohort reduced by 1% and the PSA at diagnosis reduced by 9%. In younger men (<50 years), the rate of significant cancer detection increased by 18%. CONCLUSIONS: Significant PCa detection increased across all age groups but recently, a younger patient profile was diagnosed with high-grade disease. This paves the way for future research on early-onset PCa. Younger patients with significant disease would result in increasing number of patients being eligible for radical treatment with implications on health resource planning and provision.

The role of reconstructive surgery in patients with end-stage interstitial cystitis/bladder pain syndrome: is cystectomy necessary?

INTRODUCTION: Interstitial cystitis is a debilitating condition that has a profound effect on quality of life. Although many approaches to treatment have been explored, no consistently effective treatment has been identified. Reconstructive surgery is offered to patients with refractory IC/BPS; however, expert opinion is divided as to whether simultaneous cystectomy is necessary to achieve symptomatic cure. The aim of this study was to report our experience in the surgical management of IC/BPS in a university teaching hospital. METHODS: The hospital inpatient enquiry (HIPE) system was used to identify patients with IC/BPS who underwent surgery between 1997 and 2013. Medical records were examined and patients were invited to complete three symptom-based questionnaires. RESULTS: Twelve patients were identified (8 female, 4 male). Reconstructive procedures included urinary diversion without cystectomy (9) and augmentation ileocystoplasty (4). One patient failed to have a sustained improvement in symptoms following ileocystoplasty and later underwent successful urinary diversion. All other patients noted a "marked improvement" in overall symptoms on global response assessment (GRA) and the resolution of bladder pain on a visual analogue sale (VAS). There were no persistent symptoms or complications related to the retained bladder following diversion. CONCLUSION: Our study adds to the existing evidence that cystectomy is not necessary to provide symptomatic cure in patients with end-stage IC/BPS. Urinary diversion without cystectomy is a highly effective operation and a successful outcome was achieved in all patients. Ileocystoplasty may be offered in carefully selected cases.

Life expectancy calculation in urology: Are we equitably treating older patients?

INTRODUCTION: The aim of our study was to determine the contemporary practice in the utilization of life expectancy (LE) calculations among urological clinicians. MATERIAL AND METHODS: Members of the Irish Society of Urology (ISU) and the British Association of Urological Surgeons (BAUS) completed a questionnaire on LE utilization in urological practice. RESULTS: The survey was delivered to 1251 clinicians and the response rate was 17% (n = 208/1251). The majority (61%, n = 127) of urologists were aware of methods available for estimated LE calculation.Seventy-one percent (n = 148) had never utilized LE analysis in clinical practice and 81% (n = 170) routinely used 'eyeballing' (empiric prediction) for estimating LE. Life expectancy tables were utilized infrequently (12%, n = 25) in making the decision for treatment in the setting of multi-disciplinary meetings. CONCLUSIONS: LE is poorly integrated into treatment decision-making; not only for the management of urological patients but also in the multidisciplinary setting. Further education and awareness regarding the importance of LE is vital.

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.

Experience with sliding-clip splenorrhaphy for splenic injury during radical nephrectomy.

INTRODUCTION: We report our experience with sliding-clip splenorrhaphy (SCS), a novel splenic conservation technique, for iatrogenic splenic injury (ISI) during a left radical nephrectomy (RN). We also reviewed the literature on ISI. METHODS: We retrospectively reviewed data from patients who had RN between January 2005 and December 2013 at our institution. The technique used was similar to sliding-clip renorrhaphy. Our Medline literature identified articles containing "splenic injury during nephrectomy," "iatrogenic splenic injury." "iatrogenic splenectomy," and "splenorrhaphy." Our primary outcome measures included incidence of splenic injury and splenic conservation rate and splenectomy. RESULTS: Among the 370 RN, 140 were left sided. ISI injury occurred in 6 left RN (incidence 1.6% for all nephrectomies, 4.2% for left-sided nephrectomies). All 6 cases had open procedure and for the left-sided procedure. Splenic conservation was attempted in 4 patients using SCS and 3 out of 4 were successfully repaired. Altogether 3 patients had splenectomy (incidence 0.8% for all nephrectomies, 2.1% for left-sided nephrectomies). Our literature review revealed that the incidence of iatrogenic splenectomy during left nephrectomy varies from 1.3% to 13.2%. CONCLUSIONS: SCS is an acceptable novel splenic conservation technique due to its ease of use and success in selected patients with ISI. There is little evidence on the true incidence of ISI especially on splenic conservation during nephrectomy. Every attempt at splenic conservation is likely to improve immediate- and long-term patient outcomes.

Are Adult Ureteroscopes Safe in the Management of Urolithiasis in a Pediatric Population?

INTRODUCTION: Debate remains regarding the optimal caliber of ureteroscopes in the management of pediatric urolithiasis, ranging from pediatric scopes to standard scopes. The aim of this study was to assess the safety and efficacy of stone management in a pediatric population using standard adult ureteroscopes. METHODS: A retrospective review of all ureteroscopic procedures in patients under the age of 16 years was carried out. Standard adult 7.5 French semi-rigid and 6 French flexible ureteroscopes were used. RESULTS: During the study period, 8 patients underwent 21 ureteroscopic procedures. Two patients had rigid ureteroscopy, seven had flexible ureterorenoscopy and one had a subsequent open procedure. No patients required ureteric dilation. Double J ureteric stents were utilized in 7 patients. There were no complications. All patients required extra corporeal shock wave lithotripsy. Stone clearance was achieved in all patients. CONCLUSION: Our series demonstrates that, in skilled hands, adult ureteroscopes can be use safely for the treatment of urolithiasis in pediatric patients.