Improving the Quality of Transurethral Resection of Bladder Tumour (TURBT) Operative Notes Following the European Association of Urology Guidelines: A Completed Audit Loop Study.

Background The European Association of Urology (EAU) recommends that the operative steps and documentation necessary for successful and appropriate management of bladder cancer include identifying factors necessary to assign disease risk stratification, clinical stage, adequacy of resection and the presence of complications and immediate intravesical chemotherapy administration. Aim To assess and improve the adequacy of current transurethral resection of bladder tumour (TURBT) documentation at a district general hospital in the UK against the EAU 2022 guidelines. Methods Operative notes over a one-year period were assessed for the inclusion of key steps to achieve a comprehensive TURBT as outlined by EAU guidelines. Outcomes included documentation on the details of the operative findings and intervention as well as the perioperative assessment. A standardised template for TURBT procedures was created and surgical staff received training on its usage. The audit was subsequently repeated after six months to assess for improvements. Results TURBT documentation of 78 cases in the first cycle was compared to 37 cases from the second cycle. Significant improvements in the documentation of tumour size (46% to 89%; p<0.05), tumour description (59% to 89%; p <0.05), depth of resection (36% to 89%; p<0.05), administration of chemotherapy (21% to 46%; p<0.05) and assessment for perforation (22% to 68%; p=0.001) were demonstrated. Improvements in pre-operative and post-operative examination rates under anaesthesia also achieved statistical significance (47% & 14% respectively to 89%; p<0.05). There was an increase in the documentation of completeness of resection but this did not achieve statistical significance (59% to 68%; p=0.42). Conclusion The operative note template led to the improvement in the documentation, improving the risk stratification of bladder cancer in patients undergoing TURBT. The use of procedure-specific operative note templates should be adopted for all commonly performed procedures to improve the completeness of documentation.

Stent diameter and stent-related symptoms, does size matter? A systematic review and meta-analysis.

The ureteral insertion of a silicone tube was first performed in 1967. A validated ureteral stent symptom questionnaire (USSQ) is used for an objective assessment of patient-reported stent-related symptoms. As the impact of stent diameter on the incidence of stent-related symptoms is unclear, we aimed to perform a systematic review and meta-analysis comparing USSQ reported outcomes when using a 6 Fr diameter ureteric stent, versus smaller diameter stents (4.7-5 Fr) when inserted for ureteric stones. All randomized control trials and comparative studies of 6 Fr versus 4.7-5 Fr ureteric stents were reviewed. The USSQ outcomes were considered as the primary outcome measures while stent migration was considered as a secondary outcome measure. A total of 61 articles were identified of which four studies met the eligibility criteria. There was a statistically significant association between the use of wider (6 Fr) diameter stents and the incidence of urinary symptoms as measured by the urinary index score. Larger stent diameters were associated with a statistically significant increase in the pain index score. There was no statistically significant difference in the scores between the compared stent diameters with regard to work performance score, general health index score, additional problems index score, and stent migration. There were insufficient reported outcomes to perform a meta-analysis of sexual matters index score. Our meta-analysis shows that using smaller diameter ureteric stents is associated with reduced urinary symptoms and patient-reported pain. Other USSQ parameter outcomes are statistically similar in the 6 Fr ureteric stent cohort versus the 4.7-5 Fr ureteric stent cohort. Our meta-analysis was limited due to the limited number of studies and gross heterogeneity of reporting parameters in various studies. We hope a large-scale homogeneous randomized control trial will further shed more insight into the stent symptoms response to stent diameter.

Safety and Efficacy of Transurethral Resection of Bladder Tumor Comparing Spinal Anesthesia with Spinal Anesthesia with an Obturator Nerve Block: A Systematic Review and Meta-analysis.

Aims: To investigate whether spinal anesthesia with an obturator nerve block (SA+ONB) can be effectively used for transurethral resection of bladder tumor (TURBT) during the coronavirus disease 2019 (COVID-19) pandemic to improve patient outcomes while also avoiding aerosol-generating procedures (AGPs). We aimed to compare outcomes of TURBTs using spinal anesthesia (SA) alone vs SA+ONB in terms of rates of obturator reflex, bladder perforation, incomplete tumor resection, tumor recurrence, and local anesthetic toxicity. Methods: We conducted a comprehensive search of electronic databases (MEDLINE, PUBMED, EMBASE, CINAHL, CENTRAL, SCOPUS, Google Scholar, and Web of Science), identifying studies comparing the outcomes of TURBT using SA vs spinal with an ONB. The Cochrane risk-of-bias tool for randomized-controlled trials (RCTs) and the Newcastle-Ottawa scale for observational studies were used to assess the included studies. Random effects modeling was used to calculate pooled outcome data. Results: Four RCTs and three cohort studies were identified, enrolling a total of 448 patients. The use of SA+ONB was associated with a significantly reduced risk of obturator reflex (p < 0.00001), bladder perforation (p = 0.02), incomplete resection (p < 0.0001), and 12-month tumor recurrence (p = 0.005). ONB was not associated with an increased risk of local anesthetic toxicity (0/159). Conclusion: Our meta-analysis suggests that TURBT using SA+ONB is superior to the use of SA alone. During the COVID-19 pandemic, where avoidance of AGPs such as a general anesthesia is paramount, the use of an ONB with SA is essential for the safety of both patients and staff without compromising care. Further high-quality RCTs with adequate sample sizes are required to compare the different techniques of ONB as well as comparing this method with general anesthesia with complete neuromuscular blockade.

Safety and Efficacy of Bipolar Transurethral Resection of the Prostate vs Monopolar Transurethral Resection of Prostate in the Treatment of Moderate-Large Volume Prostatic Hyperplasia: A Systematic Review and Meta-Analysis.

Aims: To compare outcomes of monopolar vs bipolar transurethral resection of the prostate (TURP) in the management of exclusively moderate-large volume prostatic hyperplasia in terms of maximum flow rate as a surrogate for clinical efficacy, duration of catheterization, hospital stay, operative time, resection weight, transurethral resection (TUR) syndrome, acute urinary retention (AUR), clot retention, and blood transfusion. Methods: We conducted a search of electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, and CENTRAL), identifying studies comparing the outcomes of monopolar and bipolar TURP in the management of large-volume prostatic hyperplasia. The Cochrane risk-of-bias tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa scale for observational studies were used to assess included studies. Random effects modeling was used to calculate pooled outcome data. Results: Three RCTs and four observational studies were identified, enrolling 496 patients. No difference was observed in the clinical efficacy between each procedure at 3 months postoperatively (p = 0.99), 6 months (p = 0.46), and 12 months (p = 0.29). The use of bipolar TURP was associated with significantly shorter inpatient stay (p = 0.01) and a shorter duration of catheterization (p = 0.05). Monopolar TURP was associated with an increased risk of TUR syndrome (p = 0.03). Operative time (p = 0.58), resection weight (p = 0.16), AUR (p = 0.96), clot retention (p = 0.79), and blood transfusion (p = 0.39) were similar in both groups. Conclusion: Our meta-analysis demonstrated that bipolar TURP in the treatment of moderate-large volume prostatic disease may be associated with a significantly lower rate of TUR syndrome and shortened length of hospital stay, with similar efficacy when compared with monopolar TURP. Further high-quality RCTs with adequate sample sizes are required to compare both monopolar and bipolar TURP to open prostatectomy or laser enucleation in the treatment of exclusively large-volume prostates with stricter definition of size.

Intraoperative Fluoroscopic Radiation Exposure During Hip Fracture Fixation: A Study Combining Surgical Experience and Fracture Complexity.

Aim Hip fracture fixation surgeries are one of the most common surgeries that every trauma unit does regularly. Surgical training and expertise to fix these fractures properly are quite crucial for every orthopaedic surgeon. Therefore, orthopaedic training programmes all over the world consider significant focus on this and teach trainee surgeons expectantly to manage these fractures independently. Surgical fixation of hip fractures often requires fluoroscopy assistance in the operating theatre with associated hazards from ionising radiation. Moreover, hip fractures can be sometimes quite complex and may require relatively more fluoroscopy usage even with the higher grade of the operating surgeons. Therefore, training need for hip fracture fixation surgery is imperative and there is also a need for intraoperative radiation safety. This study has tried to find a balance between intraoperative fluoroscopic radiation exposure, surgical training requirement, and hip fracture complexity. Methodology This single centre study has collected retrospective peri-operative data over a period of two years including hip fractures that required fluoroscopy-guided surgical fixation. Femoral head fractures, subtrochanteric fractures, diaphyseal fractures, and trochanteric fractures with associated pelvic fractures were excluded from the study. We collected data on demographic parameters, fracture complexity and grading (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] Classification), intraoperative ionising radiation exposure (centi-Gray/cm2), and grade of the operating surgeon in order to find any relation between these factors. Results Total 268 patients were included in the study with a mean age of 81.8 years (SD 9.3) comprising of 83 (31%) male patients and 185 (69%) female patients. The study population was further stratified into three groups depending upon the operating grade of the surgeon: 'Junior Trainee' (five years of experience; 148 cases [55%]); and 'Consultant' (fully trained to practice independently; 43 cases [16%]). There was no statistically significant difference among these three sub-groups with regards to the age (p = 0.79), gender (p = 0.73), body mass index (p = 0.46), and fracture pattern (p = 0.96) of the patients. However, consultants tend to operate more on the higher American Society of Anesthesiologists (ASA) grade patients (p = 0.049) with more comorbidities. There was statistically significant higher fluoroscopic radiation exposure while junior trainee surgeons (p = 0.005) were operating and during the higher complex grade of hip fracture (p = <0.001) fixation. Conclusion In conclusion, the quantity of intra-operative radiation dose utilised in the surgical fixation of hip fractures is significantly associated with the grade and level of training of the operating surgeon and fracture complexity type. The results of this study emphasise and support the importance of comprehensive, supervised, and structured orthopaedic training for in-theatre radiation safety. It is recommended to have a safe balance between teaching, learning, and prevention of ionising radiation hazards in order to optimally achieve trainee's professional development with successful patient outcomes.

A quality improvement project to assess and refine the handover process at morning trauma meetings.

BACKGROUND: Poor handover and inadequate transmission of clinical information between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK district general hospital. METHODS: A prospective single centre observational study was performed at an acute NHS trust, using the define, measure, analyse, improve and control (DMAIC) methodology. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeon's recommendations for effective handover (2007) to create a standard operating protocol (SOP). Following the implementation of the SOP, a further eight consecutive weekday trauma meetings, involving a further 47 patients, were observed. The data collection was performed by five trained independent observers. The data was analysed using t-test for quantitative variables and chi-square or Fisher's exact tests for categorical variables. RESULTS: An improvement in the trauma handover was demonstrated in multiple aspects of trauma handover including patient's past medical history, date of injury, results, diagnosis, consent, mark and starvation status (all p < 0.001). Subgroup analyses showed that handover of neck of femur patients including information on baseline mobility (p = 0.04), Nottingham Hip Fracture Score (p = 0.01), next of kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following our interventions. CONCLUSION: These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.

Comparison of the Efficacy of Male Sexual Activity Versus Alpha-Blockers in the Expulsion of Distal Ureteric Stones: A Systematic Review and Meta-Analysis.

Globally, the prevalence of urolithiasis is increasing, with limited effective treatment options. Though debate exists within the literature, the use of medical expulsive therapy (MET) for distal ureteric stones in the form of alpha-blockers is commonplace. Alpha-blockers work via the inhibition of norepinephrine, resulting in a small degree of distal ureteric relaxation. Nitric oxide (NO), the main neurotransmitter involved in penile erection, causes smooth muscle relaxation of the distal ureter. It is hypothesised that these alternative pathways may achieve the same desire clinical effect. To our knowledge, this is the first meta-analysis comparing the efficacy of male sexual activity, in the form of intercourse or masturbation, to alpha-blockers in the expulsion of ureteric stones. We conducted a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, SCOPUS, CENTRAL and Google Scholar), identifying studies comparing male sexual activity versus alpha-blockers, in male patients with distal ureteric stones. The Cochrane risk-of-bias tool was used to assess the included studies. For data analysis, a random effects model was used in the event of significant heterogeneity (>75%), with fixed-effects modelling in the event of low-moderate heterogeneity. A search of electronic databases found three randomised control trials (RCTs), enrolling a total of 262 patients. There was no statistically significant difference observed when patients engaged in sexual activity rather than alpha-blocker, when looking at stone expulsion rate at two weeks (P=0.36), expulsion rate at four weeks (P=0.57), or the mean stone expulsion time (P=0.21). Furthermore, there was no significant difference observed when looking at analgesic requirements (P=0.43), or the requirement for additional procedures (P=0.57). Our meta-analysis demonstrated that male sexual activity as an alternative therapy for distal ureteric stones had comparable outcomes to the use of alpha-blocker, proving a viable alternative therapy in those patients wishing to avoid pharmacological management.