Malignant ureteral obstruction: comparison of metallic, 8 French and 6 French ureteric stents after failure of initial ureteric stent.

PURPOSE: Malignant ureteric obstruction is a significant management challenge. The failure of ureteric stents often leads to long-term nephrostomy tubes. This is delayed for as long as possible due to its' associated morbidity. Several types of ureteric stents are available, however there is little evidence demonstrating which stents are better for preventing progression to nephrostomy tubes. This study looked to determine whether a new 6 French (Fr) polymer stent, 8Fr polymer stent or metallic stent achieved a longer functional duration once the initial polymer ureteric stent failed. METHODS: A retrospective, longitudinal study was performed at a single tertiary institution. All patients who underwent ureteric stenting with a 6Fr polymer stent for malignancy between 2010 and 2020 were included. Patients were followed up until death with ureteric stent in situ or permanent nephrostomy tube insertion. RESULTS: A total of 46 patients (66 ureters) had ureteric stents inserted for malignancy. From initial ureteric stent failure, 10 stents were changed to a new 6Fr polymer stent, 42 were changed to an 8Fr polymer stent and 14 were changed to a Resonance® 6Fr metallic stent. The Resonance 6Fr metallic stent had the longest median functional duration of 14 months (p = 0.012). CONCLUSION: Resonance® 6Fr metallic stents appear to have a significantly longer functional duration than a new 6Fr polymer stent or 8Fr polymer stent, which may allow patients to enjoy a better quality of life and delay permanent nephrostomy tube insertion.

Delays in the diagnosis and initial treatment of bladder cancer in Western Australia.

OBJECTIVES: To quantify and examine the causes of delays in the diagnosis and initial treatment of patients with bladder cancer in Western Australia. SUBJECTS AND METHODS: All attendances at a one-stop haematuria clinic at a public tertiary-level hospital in Western Australia between May 2008 and April 2014 were reviewed retrospectively. All patients diagnosed with a bladder tumour over this period were identified. These patients and their general practitioners were contacted retrospectively and invited to participate in telephone interviews, with additional data collected from clinical records as required. Waiting times to presentation, referral, assessment, and initial treatment were established for patients who presented with visible haematuria. RESULTS: Of 1 365 attendances, 151 patients were diagnosed with a bladder tumour and 100 of these were both suitable and agreed to participate in the study. For patients with visible haematuria the median (range) waiting time from initial bleeding to surgery was 69.5 (9-1 165) days. This was comprised of a median (range) pre-referral waiting time of 12 (0-1 137) days, assessment waiting time of 23.5 (0-207) days, and treatment waiting time of 20 (1-69) days. Reasons for prolonged waiting times included poor public awareness, patient fear and anxiety, delayed and non-referral from primary care, administrative delays, and resource limitations. CONCLUSION: Many patients experience significant delays in the diagnosis and treatment of their bladder cancer in Western Australia, and this probably reflects national trends. These concerning data warrant consideration of how delays can be reduced to improve outcomes for these patients.

Retrograde ureteric stent insertion in the management of infected obstructed kidneys.

OBJECTIVES: To quantify the outcomes of retrograde ureteric stenting in the setting of infected hydronephrosis secondary to ureteric calculi. PATIENTS AND METHODS: Prospective analysis of all patients over a 15-month period admitted with infected obstructed kidneys secondary to ureteric calculi. Inclusion criteria were based on clinical evidence of systemic inflammatory response syndrome (SIRS) and radiological evidence of obstructing ureteric calculi. Outcome measures included success of procedure, admission to intensive care unit (ICU), length of hospital stay, morbidity, and all-cause mortality during hospital admission. RESULTS: In all, 52 patients were included. Success of retrograde ureteric stenting was 98%. In all, 17% of patients required an ICU admission, with a post ureteric instrumentation ICU admissions rate of 6%. The mean white cell count and serum creatinine improved significantly after the procedure. Major complication rate included septic shock 6%, but there were no episodes of major haemorrhage and no deaths. CONCLUSION: Retrograde ureteric stenting is safe and effective in infected obstructed kidneys with results comparable to percutaneous nephrostomy tube insertion. Post instrumentation ICU admissions occur in 6% of retrograde stentings.

The conservative management of renal trauma: a literature review and practical clinical guideline from Australia and New Zealand.

OBJECTIVE: To review the literature and make practical recommendations regarding the conservative management of renal trauma. PATIENTS AND METHODS: Relevant articles and guidelines published between 1980 and 2014 were reviewed. Graded recommendations were constructed by a multi-disciplinary panel consisting of urologists, radiologists, and infectious disease physicians. These recommendations underwent formal review and debate at the Western Australian USANZ 2013 state conference, and were presented at the USANZ 2014 annual scientific meeting. RESULTS: The literature on the conservative management of renal trauma is reviewed within the framework of the American Association for the Surgery of Trauma (AAST) kidney injury severity scale. Graded recommendations are made regarding several key topics including: imaging, inpatient management, antibiotics, return to activity, and follow-up. Grade IV injuries and intraoperative consults are examined separately in view of the difficulties these groups cause in making appropriate treatment decisions. CONCLUSION: A practical clinical guideline is provided regarding the conservative management of renal trauma.

Are systematic prostate biopsy still necessary in biopsy naive men?

PURPOSE: Multiparametric MRI and the transperineal approach have become standard in the diagnostic pathway for suspected prostate cancer. Targeting of MRI lesions is performed at most centers, but the routine use of systematic cores is controversial. We aim to assess the value of obtaining systematic cores in patients undergoing cognitive fusion targeted double-freehand transperineal prostate biopsy. MATERIALS AND METHODS: Patients who underwent a cognitive fusion, freehand TPB at a single tertiary urology service (Perth, Australia) between November 2020 and November 2021 were retrospectively reviewed. Patients were included if they were biopsy naive and had a clinical suspicion of prostate cancer, based on their mpMRI results. Both targeted and systematic cores were taken at the time of their biopsy. RESULTS: One hundred forty patients suited the selection criteria. Clinically significant cancer was identified in 63% of patients. Of those that had clinically significant cancer, the target lesion identified 91% of the disease, missing 9% of patients whom the target biopsy detected non-clinically significant cancer but was identified in the systematic cores. Higher PI-RADS category patients were also found to be associated with an increasing likelihood of identifying clinically significant cancer within the target. CONCLUSIONS: In patients with PI-RADS 3 and higher, the target biopsy can miss up to 9% of clinically significant cancer. Systematic cores can add value as they can also change management by identifying a high-risk disease where only intermediate cancer was identified in the target. A combination of targeted and systematic cores is still required to detect cancer.

Bilateral renal papillary hyperplasia: A rare cause of visible haematuria conservatively managed.

Visible haematuria is a common presentation for investigation. Haematuria should be investigated thoroughly to exclude malignancy. Renal papillary hyperplasia is a rare, benign condition that can cause problematic haematuria. There are no currently management guidelines, as there are only few cases reported. We report a case of NSAID induced visible haematuria due to bilateral renal papillary hyperplasia and managed conservatively.

Spontaneous retroperitoneal haemorrhage following re-perfusion of an ischaemic kidney leading to emergency trauma nephrectomy.

Here we present a rare case of life-threatening spontaneous renal haemorrhage following elective vascular surgery. A 73-year-old gentleman presents to the ED with acute onset right sided flank pain, 24 hours post bilateral renal artery stent insertion for renal artery stenosis. Subsequent angiography demonstrated bilateral renal artery stent occlusion with near complete bilateral kidney infarction. The patient urgently underwent bilateral renal artery thrombectomy. Post-operatively the patient developed severe unilateral flank pain and became haemodynamically unstable. Subsequent imaging revealed a large right sided retroperitoneal haematoma with active arterial bleeding. The patient ultimately underwent a right sided trauma nephrectomy for haemorrhage control.

Fremantle protocol: Multicenter clinical outcomes for a pragmatic protocol for intravesical bacillus Calmette-Guerin.

OBJECTIVES: To examine the utility and efficacy of a multifaceted protocol for the administration of intravesical bacillus Calmette-Guerin (BCG) for non-muscle-invasive bladder cancer (NMIBC). SUBJECTS AND METHODS: A multicenter retrospective review was conducted among 83 patients undergoing Fremantle protocol intravesical BCG for NMIBC within 4 major hospitals in Western Australia between January 2016 and December 2018. The Fremantle protocol consists of weekly BCG instillations for 6 weeks during the induction phase, followed by monthly BCG instillations for 10 months during the maintenance phase with integrated clearance-to-proceed algorithms for urine MSU checks, flexible cystoscopies performed at 3 monthly intervals during maintenance BCG, and repeat GA cystoscopies with four quadrant bladder biopsies routinely obtained following the completion of induction and maintenance treatment. RESULTS: For patients undergoing Fremantle protocol BCG, 98.8% (82/83) and 75.9% (63/83) of patients completed their induction and maintenance courses of BCG, respectively. Induction BCG was delivered over a median duration of 35 days (range 34-84 days), and maintenance BCG was delivered over a median duration of 266 days (range 1-682 days). The tumor recurrence rate was 10.8% (9/83) at the time of post-induction biopsies, 2.4% (2/83) during maintenance treatment, 0% (0/60) at the time of post-maintenance biopsies, and 8.8% (5/57) after a median further follow-up of 16 months (range 0-51 months). CONCLUSION: The Fremantle protocol appears to be a safe and effective BCG regimen with several advantages over other BCG protocols, including high completion rates, low recurrence rates, and being highly pragmatic.

Trainee underperformance: a guide to achieving resolution.

BACKGROUND: Underperformance and the disharmony it can cause are not commonly faced by trainees. However, when it occurs, a process to recognize and manage the issues compassionately must be put in place. METHOD: A literature review was undertaken to outline processes and themes in addressing and resolving these types of issues. A PubMed search using 'surgical underperformance' and 'remedial teaching' was used as a broad template to find papers that illustrated key concepts. One thousand four hundred and fifteen papers were identified. In papers where the titles were in line with the stated topic, 294 abstracts were reviewed. Key papers were used to develop themes. Additional cross-referenced papers were also included where relevant. RESULTS: There can be a variety of reasons for trainee underperformance. The root cause is not always clear. Disharmony can result in a surgical unit during this time. The involved trainee as well as the members of the clinical unit may experience a variety of stressors. A systematic process of management can be used to evaluate the situation and bring some resolution to difficulties in working relationships. CONCLUSION: Early constructive intervention improves outcomes. There should be a process to systematically and compassionately resolve underlying issues. This paper outlines the disharmony that can result from trainee underperformance and offers guidance for resolution to those involved.

Renal colic: a prospective evaluation of non-enhanced spiral CT versus intravenous pyelography.

The aim of this study was to compare non-enhanced spiral CT (NECT) and intravenous pyelography (IVP) in patients with suspected acute renal colic. Two-hundred patients presenting to the Emergency Department with suspected acute renal colic were randomized into groups undergoing NECT or IVP. The main outcome measures were diagnostic utility, incidence of alternative diagnoses, requirement for further imaging, length of hospital stay, urological intervention rates, radiation dosage and costs. Non-enhanced spiral CT was better than IVP in making a definitive diagnosis of ureteric calculus or of recent calculus passage (65/102 or 66% vs 42/98 or 41%; P = 0.003). Calculi were missed in two patients in the IVP group. Two patients in each group had alternative diagnoses by initial imaging. There was no difference in the length of hospital stay or intervention rate. More plain X-rays during admission and more IVPs during follow up were performed in the NECT group. Effective radiation dosages were 2.97 mSv (IVP) and up to 5 mSv (NECT). Non-enhanced spiral CT provided greater diagnostic utility in this randomized comparison but no difference in measured outcomes. The incidence of alternative diagnoses was low, probably due to patient selection. Financial costs for each modality are comparable in a public tertiary hospital. Radiation dosages are higher for NECT and, for this reason, it might be appropriate to consider limiting NECT use to patients who have do not have classical symptoms of renal colic, to older patients and those with a contraindication to the administration of intravenous contrast media.